
Class ^f^j^ ^ 

Book j. 

Copyright IS 10 ___ 



COPYRIGHT DEPOSIT. 



PAINLESS CHILDBIRTH 



PAINLESS CHILDBIRTH 



A GENERAL SURVEY OF ALL PAINLESS METHODS 

WITH SPECIAL STRESS ON "TWILIGHT SLEEP" 

AND ITS EXTENSION TO AMERICA 



BY 

MARGUERITE TRACY 

AND 

MARY BOYD 



WITH NINETEEN ILLUSTRATIONS FROM PHOTOGRAPHS 




NEW YORK 

FREDERICK A. STOKES COMPANY 

MCMXV 



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Copyright, 1915, by 

Frederick A. Stokes Company 



All rights reserved, including that of translation 
into foreign languages 




March, 1915 



MAR 29 1915 

©CI.A3'97313 



TO M-L.P- 



WHOSE PRACTICAL WORK IN DAMMERSCHLAF IS ENSHRINED 
IN THE LOVING TESTIMONY OF THOUSANDS OF MOTHERS, 
AND WHO, BUT FOR THE ANONYMITY OF HER SERV- 
ICE WOULD BE KNOWN TO-DAY AS ONE OF THE 
FOREMOST OBSTETRICAL ANAESTHETISTS. 



If a woman becomes weary and at last dead from bearing , 
that matters not; let her only die from bearing. She is there 
to do it. 

MARTIN LUTHER 



It is inconsistent for the Church to oppose painless child- 
birth when it has not opposed painless surgery. For the same 
passage in Genesis enjoins on man suffering throughout his 
life, and on woman sufering in childbirth. 



A CLERGYMAN OF TO-DAY 



CONTENTS 



PAGE 

Intkoduction xxix 



CHAPTER I 
THE FRAUENKXINIK : A DAY IN JUNE 

The Klinik Mothers 1 

German controversy on the Freiburg experiment ... 2 

The Geheimrat and his patients 4 

The first American mother's story 5 

A typical Dammerschlaf 9 

A typical convalescence 14 

Medical science localises the experience 16 

The mothers spread it abroad 17 



CHAPTER II 

PROFESSOR KRONIo's TALK TO THE WOMEN OF FREIBURG 

The lost speech and its echoes 18 

"Kronig 1908" — his address to his students . . . .21 

The "rescuing" forceps 23 

Exhaustion through pain a cause of its use .... 23 

Pain of birth not physiological, but pathological, in its effect . 23 

Breakdown often follows painful birth 24 

General attitude of the medical practitioner towards pain in 

birth 26 

James Young Simpson on pain as a danger to the birth process 26 

ix 



x CONTENTS 

PAGE 

Familiarity with pain brutalises the doctor .... 27 

The pain of birth equal to the pain of surgery .... 27 

Evidence in regard to the acuteness of birthpain ... 28 

The physiological function of birthpain 28 

Destruction of vitality by pain 29 

Removal of pain saves vitality for resisting the emergencies of 

birth 29 

Birchmore on birth relieved of the impediment of pain . . 30 
His painless cases show muscular contractions normalised by 

removal of pain and dilatation furthered .... 30 

They show less laceration 30 

Pain lengthens labour 31 

Pain often makes forceps and other operations necessary . .31 

Injury to the child through mother's pain 31 

Operative frequency under painlessness cut in half . . .31 

Kronig on convalescence from painless birth .... 32 

Gauss on painless birth 32 



CHAPTER III 
FEAB AND PAIN I THE PSYCHOLOGY OF MATERNITY 

Actual fear of childbirth, as opposed to hysterical apprehen- 
sions disregarded by the obstetricians .... 33 

Birchmore on fear 33 

Kronig on fear 33 

Fear part of traumatic shock of childbirth .... 34 

Butler on the place of fear throughout childbearing period . 34 

This fear dominates some women's lives 34 

A few sensitive obstetricians take account of the farreaching 

consequences of both fear and pain in childbirth . . 37 
Effect of pain on the nervous system . . . ... .38 

Puerperal psychosis 38 

Relation of fear to this and to psychosis in pregnancy . . 38 

The young girl's fear of marriage 39 

The desire for a child fights with fear of childbirth . . 39 

Deceptive natural amnesia 39 

The fear that follows one painful birth 39 



CONTENTS xi 

PAGE 

Hysteria derived from the Greek word for womb ... 40 
Nerves broken down by painful birth sometimes simulate uter- 
ine disease 40 

Gauss's testimony to this 40 

Possible effect of birthpain on women's mental development . 41 
Women have faced painful childbirth bravely as long as it was 

unavoidable 42 

From Genesis on, childbirth has been the literary exemplum 

of pain 42 

Birth rate contrasted with death rate; sum of suffering through 
birth and the ills following greater than through disease 

and death 42 

Dammerschlaf does away both with painful birth and with 

much uterine disease 42 

Harper's Weekly speaks of desirability of perpetuating birth- 
pain 43 

Stoical women desire birthpain 43 

These put courage above the conserved vitality which they 

could expend on their children after a painless birth . . 43 

Peace of mind part of prenatal care for mother and child . . 44 

Burdens of pregnancy are enough 44 

Birth should be a rite to maternity, not an animal agony . . 44 



CHAPTER IV 

GAUSS AND DAMMERSCHLAF: 80% PERFECT 

"Gauss 1906": personality and work of the author ... 46 

Scope and method of his 1906 report 47 

The state of Dammerschlaf defined 47 

The ideal state for the birth process 48 

Atropin-hyoscin-scopolamin family 48 

Earlier use of scopolamin in obstetrics 48 

Gauss's infinite pains in working out the technique of Dammer- 
schlaf 49 

Perfect Dammerschlaf 49 

First experimental mothers were dogs 49 



xii CONTENTS 

PAGE 

"Gauss 1906" (Births in Artificial Dammerschlaf ) ; study of 

first 500 human mothers . .50 

This report stands alone, for scope and the care with which de- 
tails are studied, in obstetrical literature .... 50 
Later reports on 1,000 cases (1907) ; on 3,000 (1911) ; on 600 

(1913) and on 511 (1914) 50 

Work at Freiburg not an experiment but a proved experience 50 

"Touchstone" for all obstetrical use of scopolamin-morphin . 51 
Kelation of Gauss's 1906 to later reports . . . .51 
Three stages of Dammerschlaf: painlessening, partial, and deep 

Dammerschlaf 51 

Introduction of Dammerschlaf described by Gauss . . .51 
Semi-narcosis and artificial Dammerschlaf compared ... 53 
Forgetfulness characteristic of this condition of clouded con- 
sciousness 54 

Examples 55 

Amnesia 56 

Derangement of apperception the sign of amnesia; "memory 

test" the means of maintaining Dammerschlaf ... 57 
Pupillary reaction and locomotor ataxia also signs of Dam- 
merschlaf 57 

Difficulties in guiding Dammerschlaf 58 

Disturbances of the senses 58 

Antiphones and mask 59 

Muscular sensation 59 

Touch and perception of pain 60 

Method stands or falls by the memory test 60 

Amount and regulation of dose of scopolamin and morphin . 60 
Percentage of success in free wards smaller because of dis- 
turbances of the senses 61 

Percentage of complete and partial success in Gauss's first 500 

cases 61 

Percentage in his later studies 61 

Percentage in first ward 61 

Gauss laid down conditions for his work, for safety of mother 

and child 62 

His early experience led him after the experimental stage was 
passed to offer Dammerschlaf to all mothers in active 

labour 62 

His statement on this matter in America 62 



CONTENTS xiii 

PAGE 

Gauss on painlessness as an aid to birth; preventing secondary 
insufficiency during birth and nervous-uterine diseases 

after 63 

Easy convalescence 65 

Detailed studies by Gauss's assistants show duration of birth 

and muscular contractions normal 65 

They show blood loss normal 66 

They show mother and child uninjured 66 

Use of forceps under Dammerschlaf 66 

Use of other operations under Dammerschlaf .... 66 

Standardising of scopolamin by Professor Straub ... 67 

Gauss on the condition of the child 67 

Statistics of the first 500 children 68 

Oligopncea or light breathing 68 

A visiting doctor's description of oligopnea .... 69 

Asphyxia never caused by Dammerschlaf 70 

Morphin should be cut down to minimum for safety of child . 70 

Gauss cuts percentage of oligopncea in half in 1907 ... 70 

Infant death rate cut in half by Dammerschlaf at Frauenklinik 70 

Prof. Aschoff's explanation 71 

Effect of breathing impediments on later development . . 71 
Holzbach shows that minute quantities of scopolamin are soon 

thrown off by the child 72 

Mortality of Frauenklinik babies in first year of life less than 

ordinary mortality in that year in Baden .... 72 
Larger percentage of mothers confined in Dammerschlaf nurse 

their children 72 

Favourable statistics on a group of over 400 Frauenklinik 

babies followed through first year of life .... 73 
Freiburg Frauenklinik has the lowest mother and infant mor- 
tality of any maternity hospital in Europe .... 73 
General summary of Gauss's 1906 report .... 73 
Drs. Harrar and McPherson on disregard of Freiburg technique 

by other obstetricians 73 

Gauss on the advantages of Dammerschlaf 74 

What the Freiburg record has proved 74 

An 80% perfect method with small percentage of failure and 

requiring in all cases special environment for success . 74 

The future may develop a 100% perfect method .... 75 



xiv CONTENTS 



CHAPTER V 
how Simpson's method was killed 

PAGE 

The first spontaneous birth under painlessness was in 1847 . 76 
Sir James Young Simpson was not a discoverer of surgical 

anaesthesia 76 

His sole and persistent original work was for obstetrical an- 
aesthesia or painless childbirth 76 

His first case 76 

The religious controversy over use of semi-anaesthesia with ether 

and chloroform in childbirth 76 

Simpson answers his religious and medical opponents . . 77 

Story of one of Simpson's first mothers 78 

"Miss Anaesthesia" 78 

Simpson maintains semi-narcosis in spontaneous births up to 

14 hours 79 

Chloroform a la reine 79 

Simpson's summary of his results 79 

Ether a diffused stimulant in labour 79 

Dr. A. Ballantyne on Simpson's work 80 

Simpson's work better than that of most of his successors . 80 
Present administration of chloroform in obstetrics is mere un- 

standardised emergency anaesthetisation .... 80 
Examples of amateur anaesthetisation childbirth . . .81 
A. Lapthorne Smith allows the mother herself to administer 

the anaesthetic 81 

J. W. Allwright allows this also 81 

Chloroform and ether almost entirely safe in childbirth . . 82 
Skilled obstetrical anaesthetists can administer them success- 
fully for as long as 30 hours' labour .... 82 
Havelock Ellis's experience in producing practical Dammer- 

schlaf with chloroform, etc. 83 

R. C. Buist also produces this condition 83 

Buist's description of amateur methods commonly used to-day 84 
Analgesia or painlessness not amnesia is condition aimed at by 
all other methods than Gauss's ; disturbance of attention in 

Ellis's case is an accident not intentional ... 84 



CONTEXTS xv 

PAGE 

Hypalgesia or mere painlessening aimed at by most obstetrical 

anaesthetists 84 

J. P. Reynolds' experience 84 

A mother's evidence in regard to unsatisfactoriness of this 

condition 85 

No effort has been made to study and standardise the possibili- 
ties of obstetrical anaesthesia with ether and chloroform 85 

Simpson considered it the moral duty of every obstetrician to 

furnish painlessness in childbirth 86 

The Royal Medical and Chirurgical Society recognised obstetri- 
cal anaesthesia in 1860 as safe and desirable ... 86 

Yet A. Ernest Sanson speaks of the opposition offered by his 

profession to obstetrical anaesthesia 86 

Struggle for more common use by prominent obstetricians . . 86 

Reynolds and Allwright say choice should be left to mother not 

to doctor 86 

A German student of obstetrical anaesthesia finds chloroform, 
ether and scopolamin-morphin the only anaesthetics suitable 
for long births 88 

He declares that they are not used, simply because they are 

too much trouble 88 

He brings out the unstandardised character of the experience 

with chloroform and ether 88 

Little attention given to obstetrical anaesthesia in the literature 

of obstetrics 89 

Simpson's work taken little advantage of by his profession . 89 

His prophecy that women would in time themselves rebel 

against the usual tortures of childbirth is now coming true 89 

It promises to make effective the work Simpson began . . 90 



CHAPTER VI 



"time will tell": berlin to Chicago 



Gauss in 1911 on opponents and supporters of Dammerschlaf . 91 
Gauss on scope of Freiburg experience in that year . . .91 
Germany loses interest in the subject, as England had lost in- 
terest in Simpson's work .91 



XVI 



CONTENTS 



Scopolamin-morphin in obstetrics has never been discredited or 
discarded; records exist of at least 12,000 births in Ger- 
many alone 92 

Spread throughout Germany by the controversy on its use be- 
tween Berlin and Freiburg Universities .... 92 
Experimentation after von Steinbuchel; some users cautious, 

some reckless 92 

Eecklessness brought scopomorphin into disfavour ... 92 

History of scopomorphin in major surgery .... 92 

History in minor surgery and as preliminary narcotic . . 93 

Crile's use 93 

Difference between method of use and condition to be attained 

in surgery and in obstetrics 93 

Death rate for all uses compared with death rates for ether 

and chloroform 94 

"Gauss 1906" reopens experimentation in obstetrics ... 94 

His technique and dosage entirely disregarded .... 94 

In 1911 a half dozen Germans had reported on Dammerschlaf 94 
Their method compared with that of German obstetricians who 

did not use Dammerschlaf 94 

The men who disregarded Dammerschlaf technique overdosed . 95 
One child killed by this class of experimenter .... 95 
The struggle centres about the right use of scopolamin . . 96 
Disregard of Freiburg technique mainly due to jealousy of Frei- 
burg on the part of Berlin 96 

Experimentation at Berlin conducted by Hocheisen ... 96 
Debate between Gauss with 1,000 cases and Hocheisen with 100, 

in 1907 97 

Reason for their different results was use of different methods 97 

"Time will tell" 98 

Effect of this debate both bad and good in Germany: fair 

minded used Gauss's method and succeeded ... 98 

Steffen of Dresden fails 98 

Gminder 99 

Avarffy 99 

Bumm of Berlin 99 

Berlin-Freiburg controversy affects America .... 99 

French experience with scopolamin in obstetrics ... 99 

English experience 100 

Early American experience ........ 100 



CONTENTS xvii 

PAGE 

"Chicago" experiment 101 

Charles M. Green tries scopolamin in 1903 102 

Freiburg technique not used till 1914 in America . . . 102 

American dosages 102 

Overdosing with morphin before 1914 103 

A dozen American obstetricians who experimented from 1906 

to 1911 103 

Unpleasant experiences but no deaths proved . . . .103 

Reckless dosage 103 

Discouraged American obstetricians accept the judgment of 

Berlin rather than of Freiburg 104 

Some cautious American obstetricians continued their use of 

scopolamin 104 



CHAPTER VII 

TIME HAS TOLD: FREIBURG TO NEW YORK 

October, 1913, Kronig and Gauss before American obstetricians : 

October, 1913, two women go to Freiburg .... 106 
May, 1914, Kronig's American address published; May, 1914, 

McClure's publishes article on Dammerschlaf or Twilight 

Sleep '. 106 

Twilight Sleep known only to medical profession before, now 

talked of all over the world 106 

Doctors tried to discredit the facts in the magazine article . 107 
October, 1914, a persistent and general, though unorganised, 

demand among women for painless birth . . . .107 
Freiburg set the standard of obstetrical anaesthesia for the 

world; it is now handed over to women to enforce . .108 
By October the medical profession had passed from intemperate 

attack to open-minded experimentation with Twilight 

Sleep 108 

This experimentation due solely to pressure of women's demand 109 
Value of medical ethics to the physician; to the public . . 109 
O. W. Holmes's asepsis put back a generation by conservatism 

of his profession 110 

Semmelweis's contribution to the same procedure also delayed 

and himself driven insane by the same opposition . .110 



Ill 
111 



xviii CONTENTS 

PAGE 

Publicity given Twilight Sleep in popular magazines considered 

a reflection on the progressiveness of American medicine . 110 

Fear of safety and practicability of the method made Ameri 
can doctors unfavourable till they had themselves experi 
mented 

Attitude of two medical journals 

Much of the criticism of Twilight Sleep in summer of 1914 is 
in reality criticism of early unstandardised use of scopola- 
min in obstetrics 112 

Journal of American Academy of Medicine criticises . . .112 

Barton C. Hirst criticises on same basis, but with effort to 

make it seem that Freiburg method is the same . .113 

E. Gustav Zinke's criticism 113 

Charles M. Green criticises on basis of his own failures before 

Twilight Sleep existed 114 

Only a few American obstetricians would acknowledge at first 

that Freiburg method differed from their own . . .114 

Dr. Eoss McPherson's acknowledgment of this . . . .115 

Changed character of the criticisms in the late fall, after ex- 
perimentation 116 

Franklin Newell of Harvard counsels, like Gauss, extreme care 

and high skill in the use of scopolamin-morphin . . .117 

Women to some extent protected from danger of ill-informed 
general practitioner using scopolamin incautiously, by their 
own knowledge of the Freiburg requirements . . .117 

They are becoming hospitable to the idea of hospital confine 
ment 

Doctors themselves draw on popular magazine descriptions of 
the technique 

Effect of the women's demand on the general practitioner . 

Exodus of American doctors to Freiburg in summer of 1914 

Freiburg Frauenklinik accused of commercialism 

Freiburg Frauenklinik emptied of its staff by the war 

Twilight Sleep handed over to America .... 

American reports on Twilight Sleep begin in the fall 

Milwaukee Medical Society and the women of Milwaukee 

Sessions on Twilight Sleep by all medical societies throughout 
the country 

All the root and branch opposition was by those who stated 
they had not themselves used the method . 



117 

117 
118 
118 
119 
119 
120 
120 
120 

120 

120 



CONTENTS xix 



A dozen meetings on the subject in New York City . . .121 

Memorandum of Public Health Division of American Academy 
of Medicine urges investigation and makes the important 
statement, for the first time in medical history, that the 
pains of maternity should be relieved 121 

Women's Division of American Academy of Medicine as to the 
perfect practicability of Twilight Sleep 

Personal views of doctors reporting at meetings 

Opinion of Dr. Craigin 

Opinion of Dr. J. Thompson Schell .... 

Some report having used scopolamin for many years . 

Some report having failed before, but succeeded now that 
are using Freiburg method • • • 

Testimony of Dr. Bertha Von Hoosen • • • • 

Testimony of Dr. Franklin S. Newell • * • 



they 



122 
122 
123 
123 
123 

123 
124 
124 



CHAPTER VIII 

TIME HAS TOLD: AMERICAN REPORTS ON AUTHENTIC 
TWILIGHT SLEEP 

In September, 1911, the two earliest reports on series of cases 
in Twilight Sleep read before American Association of 

Obstetricians and Gynaecologists 125 

Many verbal reports on series of cases in various cities . . 125 

Siegel's method 126 

Gauss's estimate of this method 126 

The method contrasted with that of Gauss; fixed versus indi- 
vidualised dosage 126 

J. de Lee on Siegel's method 127 

Kronig on Siegel's method 128 

A case which shows the difference between the two methods . 128 

Siegel's method a menace to authentic Twilight Sleep . . 128 
Probably as many as 3,000 cases of authentic Twilight Sleep 

now exist in America 129 

Reports published by four hospitals 129 

None of the experimenters Freiburg trained but have followed 

published rules rigidly 129 

Dr. Schlossinck 129 



xx CONTENTS 

PAGE 

Drs. Rongy and Arluck's report for Jewish Maternity Hospital 

in New York 130 

Drs. Harrar and McPherson's report for New York Lying-in 

Hospital 131 

They comment on the objective symptoms of pain to be ob- 
served under Twilight Sleep 132 

They compare 100 births under Twilight with 100 births in 

consciousness, as to both mother and child . . . .133 
Need of high skill in obstetrics for best results in Twilight 

Sleep 133 

Drs. W. H. W. Knipe and J. O. Polak report on series of cases 135 
Both these men had formerly failed with scopolamin; both now 

ascribe their failure to disregard of Freiburg technique. . 135 
Dr. Polak on reasons for low mortality of mother and child at 

Freiburg 136 

Dr. Polak on value of painlessness to birth process and to 

mother and child . 136 

Effect of scopolamin on child 138 

Place of Twilight Sleep in obstetrics 140 

Dr. Polak's experience . . . 141 

Dr. Knipe on the child 141 

On avoidance of cumulative overdosing and "forcing" by Twi- 
light Sleep 142 

His experience 142 

His method of convalescence 142 

His estimate of the way in which Twilight Sleep should de- 
velop and its effect on obstetrics in the future . . .143 

The open hospital 144 

Three present menaces to Twilight Sleep 144 

Public speaking on Twilight Sleep in department stores . . 145 

A street-corner speaker 146 

Women respond as to a matter of life and death . . .146 



CHAPTER IX 

A DOZEN ANESTHETICS AND THE FOKCEPS 

Anaesthetics which give a brief relief in childbirth . . . 147 
Few of these known to the general practitioner . . . 147 



CONTENTS xxi 

PAGE 

The "doctor's discretion" is to-day being replaced by the 

mother's discretion in the use of anaesthetics in childbirth 147 

M. W. Kapp on effect of mother's pain on a sensitive doctor . 147 
A dozen anaesthetics known to the obstetrician . . . .148 

Only used in selected cases 149 

A half dozen anaesthetics can relieve first stages of labour . 149 
A considerable number can relieve final stage . . . .149 

A. Johnen's report on anaesthesia in spontaneous birth . . 149 
Conclusions as to value of the various narcotics based on 

slender, unstandardised experience 150 

In England ether or chloroform for long or short periods most 

popular 150 

In Germany, scopolamin 150 

A fairly large experience with cocain is reported . . . 151 

Hypnotism developed in France but has limited application . 151 
Many anaesthetics used in early stages combined with ether at 

end 152 

Scopolamin-morphin sometimes used this way .... 152 

Codein-digitalin-strychnia 152 

Antipyrin 152 

Nitrous oxide and oxygen 152 

Artificial premature delivery as a means of lessening pain . 153 

Its dangers to the child 153 

The "alleviating" forceps and its dangers 153 

Testimony to this by Dr. Kronig 154 

Further testimony by other obstetricians 154 

A hundred births relieved by the forceps for every one made 

spontaneous under some form of artificial painlessness . 155 



CHAPTER X 

A FRENCH EXPERIMENT OF TO-DAY 

Ribeniont-Dessaignes of Paris bases his case for artificial pain- 
lessness on its superior safety over painful birth . . 156 

He studies birth contractions as a muscular function without 

pain 156 

His testimony to value of painlessness to birth process . . 157 

Its value to convalescence 158 



xxii CONTENTS 

PAGE 

No after-pains 158 

Readjustment of organs aided 158 

Value of artificial painlessness where minor operations are sud- 
denly called for 159 

Value in eclampsia 159 

Antalgesine, the new French obstetrical narcotic . . . 159 
Still an experiment, not like Twilight Sleep, a proved experi- 
ence 159 

Ribemont-Dessaignes reports on 112 cases under Antalgesine . 160 

"A drug for the provinces" 160 

Pouchet's chemical analysis; detoxicated morphin . . . 160 

Its quick action and other advantages 160 

The state of consciousness • . .161 

The chemist Georges Paulin discovers Antalgesine . . . 162 
Ribemont-Dessaignes, "accoucheur des hopitaux," reports on 

its use and astonishes French obstetricians . . . 162 

Georges Paulin's story 165 

"Tocanalgine"— Painless Birth 166 

Paulin's hospital 167 

Ribemont-Dessaignes' story 169 

Le Laurier's report 171 

Pinard's evidence . . . 172 

French obstetricians on oligopncea 172 

An American obstetrician's experiment with Antalgesine . . 173 

He compares its effect with Twilight Sleep 173 

Strength and weakness of Antalgesine 174 

Educational value of Twilight Sleep 175 



CONCLUSION 
THE OBSTETRICS OF TO-MORROW 

Wise judgment and gentle skill characteristic of this age of 

obstetrics 176 

The general practitioner does not possess this judgment and 

skill 176 

Many lives lost through inability of doctor to perform caesarean 

section 177 

In surgery barber is replaced by skilled specialist . . .177 



CONTENTS xxiii 

PAGE 

General practitioner, obstetrician and gynaecologist now share 

care of women's sex life 177 

Gynaecologist repairs injuries done in childbirth by general 

practitioner 177 

Obstetrician not properly respected 178 

Obstetrician and gynaecologist should be one . . . .178 

T. Whitridge Williams' evidence 178 

Obstetrical anaesthesia needs the hospital and the specialist . 178 
Life-giving should be put on same high basis as life-saving in 

surgery . 179 

To-day life-giving causes a greater volume of suffering than 

disease 179 

Hospital necessary to development of obstetrics . . . .179 
Morbidity and mortality at childbirth is lowered only in the 

hospital 179 

100% perfect obstetrical anaesthesia is that which requires the 

hospital and expert care 179 

Need of hospitals for childbirth 179 

Expense of Twilight Sleep should be apportioned to patient's 
capacity to pay, supplemented by hospital endowment, as 

it is to-day in surgery 180 

Progress of obstetrics bound up in painless methods . . .180 

Cheapness of life to-day 181 

Cheapness and over-population go together 181 

Twilight Sleep entrusted to the women of America to promote 181 
A chain of Twilight Sleep hospitals or hospital wards the pos- 
sible development of the future 182 

Painless spontaneous birth should be as universal as painless 

surgery 182 

SUPPLEMENTARY CHAPTER 
HOW IT FEELS TO TAKE THE TWILIGHT SLEEP 

The Freiburg experiences of: Mrs. Cecil Stewart, Mrs. Mark 

Boyd, Mrs. Francis Carmody 185 

APPENDIX I 
Painless Delivery in Dammerschlaf. By Bernhard Kronig, 1908 205 



xxitf CONTENTS 

PAGE 

APPENDIX II 
Births in Artificial Dammerschlaf. By Carl J. Gauss, 1906 . 224 

APPENDIX III 

Further Experiments in Dammerschlaf. By Carl J. Gauss, 

1911 292 

Bibliography 309 



ILLUSTKATIONS 

The Frausriklinik of Freiburg, the place where the 
science of obstetrical anaesthesia has been worked out 
to a perfection that sets a standard for the world. 
The Frauenklinik has the lowest infant and ma- 
ternal mortality of any clinic in Europe or Amer- 
ica Frontispiece' 

FACING 
PAGE 

Jane Erin Emmet was the little girl born on a "day in 
June," when the great Berlin-Freiburg controversy 
over painless childbirth was at its height. Jane's 
brothers, Winthrop and William, both of whom were 
born under Dammerschlaf, attest to the endorsement 
of the patients who have had the benefit of Dammer- 
schlaf at the Freiburg Klinik 14' 

Mrs. Cecil Stewart was the second American woman to go 

to Freiburg for her baby 15' 

The son of a Freiburg University professor. While pro- 
fessional etiquette forbade giving the names of men 
connected with Baden University, the hearty co-op- 
eration of wives and mothers in the faculty furnished 
many photographs of their Dammerschlaf children . 30 

The four "scopolamin" children of Frau Bissinger, one of 
the women of Freiburg whose enthusiasm for Dam- 
merschlaf, together with her wide acquaintance, helped 
us to collect pictures of over two hundred Dammer- 
schlaf children 31 

"Sonny Boy," an excellent specimen of a Dammerschlaf 
baby. His father, an assistant professor of the Frei- 
burg University, uses scopolamin in preference to 
atropin in ophthalmological practice . . . .62 
xxv 



xxvi ILLUSTKATIOISrS 

FACIXG 

(a) "Volcker," of Freiburg, son of a University professor 
who has made a special study of the 50 per cent, de- 
crease in infant mortality at the Klinik since the in- 
troduction of Dammerschlaf. (b) "Peter" Straub's 
father discovered a means of preserving scopolamin in 
solution : Peter was born under its Dammerschlaf five 
years ago 63' 

Sir James Young Simpson's sole and persistent work was 
with obstetrical semi-anaesthesia, or the attaining of 
painless spontaneous birth. "My profession may never 
help me," he said once, "but women themselves will 
betimes rebel against the usual tortures and miseries 
of childbirth." 94^ 

The first "painless" child. By chloroform a la reine Sir 
James Young Simpson maintained a Dammerschlaf 
condition from six to fourteen hours . .. . 95 

Gouverneur Hospital in New York, where Mrs. Hans 
Leuderman's baby was born in January, 1914, has re- 
ported success in over 100 cases of Twilight Sleep, and 
is the only American clinic which employs the "active 
convalescence" of Freiburg 142 

(a) Barbara Jane, born under Twilight Sleep at the Wes- 
ley Hospital, Chicago, September, 1914. (b) Mrs. 
Francis Xavier Carmody and her little boy, Charle- 
magne, born July, 1914, while the visiting American 
doctors were at Freiburg, converted at least one fa- 
mous American obstetrician to Dammerschlaf . . 143 " 

Professor Weismann's great-grandchild, born under Dam- 
merschlaf in 1913. Professor Weismann was the con- 
temporary of Darwin. He was emeritus professor of 
biology at the University of Baden, and died at Frei- 
burg in 1914 174 



ILLUSTEATIONS xxvii 

FACING 

Mrs. Joseph A. Sargent and William Winthrop Home 
Sargent, one of the youngest of the American boys 
born at Freiburg. His family came up from Spain 
that he might be a Dammerschlaf baby . . . 175 ' 

"The second day after the baby was born I got up " 



From a snapshot taken by Marguerite Tracy in the 
Frauenklinik, showing Mrs. Stewart out of bed on the 
second day 190 

"Sumner," the little son of Mrs. Mark Boyd, born at Frei- 
burg in January, 1914. Mrs. Boyd turned an inter- 
ruption in the course of work into an opportunity for 
intensive work of a special kind .... 191 w 



USTTKODUCTION 

The history of painless childbirth divides itself into 
three periods. 

The first, or chloroform-ether period, began when, in, 
1848, Sir James Young Simpson administered chloro- 
form a la reine. He and a few of his followers used this 
method in such perfection that descriptions of a birth so 
conducted read like those of a birth conducted under 
Freiburg Dammerschlaf, or, as we roughly translate it in 
America, Twilight Sleep. But the general administration 
of chloroform-ether in childbirth has deteriorated so that 
the Dammerschlaf condition is now regarded as peculiar 
to Freiburg, and indeed required to be rediscovered there. 

The second, or scopolamin-morphin period, is the pe- 
riod of the present. This drug came into use in child- 
birth in 1903. Its history would have repeated that of 
chloroform, if Kronig and Gauss had not set themselves 
to work out experimentally a perfect method of dosage. 
They have furnished a standard, and recorded an experi- 
ence that lays a secure foundation on which other obstetri- 
cians can build up as perfect a science of obstetrical anaes- 
thesia as now exists in surgical anaesthesia. The Freiburg 
method worked out by Kronig and Gauss, covering as it 
does many thousands of cases over a period of ten years, 
is one of the largest experiences under uniform condi- 
tions on record in medical literature. It has shown itself 



INTRODUCTION 

to be a perfect method when it is practised in its due en- 
vironment, and when its peculiar requirements are scrupu- 
lously observed. 

It is with this second or Dammerschlaf method that we 
have at present to do. It is for this Twilight Sleep that 
the women of America are agitating. Aroused to the fact 
that such a method exists, they have fulfilled the prophecy 
made by Simpson two generations ago, when he said: 
"Women themselves will betimes rebel against enduring 
the usual tortures and miseries of childbirth." 

They are demanding that medical science shall create 
the environment, and fulfil the exacting requirements 
for Dammerschlaf, or "Twilight Sleep." 

From France, at this moment, come the first reports 
on what may prove to be a third period. Obstetricians 
of such world authority as Pinard and Ribemont-Des- 
saignes are experimenting with it, claiming for it that it 
requires no special environment or care. Although in its 
purely experimental stage, this method is reported here 
to present the views of French obstetricians of the first 
rank toward painless childbirth ; Ribemont-Dessaignes be- 
ing indeed the first scientist advocate of painless child- 
birth to base his whole case on the actual superior safety 
of the removal of pain, quite aside from humanitarian 
grounds. Ribemont-Dessaignes' s method may be said to 
represent an effort in obstetrics to work out something 
so simple that it needed no special conditions of environ- 
ment or watching for success. 

Hitherto painlessness has been provided in childbirth 
when the doctor thought the case required it. Stimu- 
lated by the Dammerschlaf, and the Freiburg ideal that 



INTKODUCTION 

all births should be made painless, the women of America 
are demanding that the administration of painlessness 
shall not be left to the decision of the doctor, but of the 
mother. The effectiveness of their demand is illustrated 
by a recent statement at a meeting of obstetricians, where, 
unchallenged, one of their number said: "The Dammer- 
schlaf can be administered safely and successfully, but 
with infinite pains to doctor and nurse. The decision as 
to whether it shall be used rests not with the doctors but 
with the women themselves." 

For two generations individual medical enthusiasts for 
obstetrical anaesthesia have from time to time demanded 
that the pains of childbirth be relieved. 

Now for the first time in the history of medicine a 
public health body has issued a memorandum to its mem- 
bers on this same theme : the pains of maternity should be 
relieved. This, coming from the Committee on Public 
Health of the Academy of Medicine, should be a justifica- 
tion of our lay agitation of the subject, if, in the minds 
of serious women, any justification is needed. 

For while to-day in all obstetrical meetings — local, state, 
and national — throughout America, the burning subject is 
Twilight Sleep, we recall that in a European review a 
year ago Kosika Schwimmer recorded that at an Inter- 
national Congress of Obstetricians then sitting, every 
aspect of childbirth was discussed except that of the possi- 
bility of relieving pain. 

Obliged to collect our material without help from prac- 
tising doctors, we have perhaps been led to study their 
works more intensively than have the students in their 
classes. And while there is certainly a whimsical novelty 



INTRODUCTION 

in the position of authors scrupulously repudiating ru- 
mours that courtesy was extended them by their authori- 
tative sources of personal information, we wish to state 
definitely that Professors Kronig and Gauss of Freiburg 
were in no way helpful to us in our researches, but on the 
contrary were baffling and obstructive to the last degree. 
Indeed, our experience at Freiburg was so difficult and 
disheartening that when it came to getting the facts about 
the French experience, under pressure of limited time, one 
of us allowed herself to be mistaken for a student of ob- 
stetrics from an American hospital. This should exon- 
erate Professor Pibemont-Dessaignes, if, like the Freiburg 
doctors, he is professionally attacked. 

We warmly acknowledge our debt of personal gratitude 
to the women of Freiburg, before whom Professor Kronig 
himself was obliged, some years ago, to state the case for 
Dammerschlaf when its medical opponents had all but dis- 
credited it by misrepresentation. The hearty and enthusi- 
astic co-operation of these Freiburg mothers, who placed 
at our service all their experience and that of their friends, 
gave us almost limitless personal sources of information 
by means of which we were able to animate and popularise 
the dry records in the German archives of gynecology and 
obstetrics. 

Of the little group of American mothers who deter- 
mined to put their personal experience of the Freiburg 
method before the women of America, Mrs. C. Temple 
Emmet was the first to test the method and to endorse it 
by returning twice to Freiburg for the Dammerschlaf. 
Her friends scarcely grasped the fact that an absolutely 
painless birth was possible for them also. Women had 



LNTEODUCTION xxxiii 

never before heard of, and could not wholly believe in, 
total immunity from pain throughout a birth. 

Until, commissioned by McClures Magazine, we began 
to study the subject, we thought that the Freiburg effort 
was unique, so utterly had Simpson's contribution to pain- 
less childbirth been allowed to die because it had been en- 
trusted to his profession. 

And while there is a novelty, not whimsical, in a body 
of women being obliged to pla.ce before the lay public of 
the world a gift of science which has by rights been its 
possession for two generations, we nevertheless do place 
this account of the long and uphill effort for painless 
childbirth in their hands. 

It is, as far as we know, the first time in the history of 
medical science that the whole body of patients have risen 
to dictate to the doctors. 

New York City,, January, 1915. 



PAINLESS CHILDBIRTH 

CHAPTEK I 

The Frauenklinik : A Day in June 

In the midst of the great controversy then at its height 
in European obstetrics, the prime cause of that contro- 
versy, Professor Bernhard Kronig, received an unusual 
patient. 

The month was June. The year 1908. The cool shade 
trees of a German garden protected the tables and chairs 
and benches where little groups of convalescent mothers 
talked over their recent experiences, speculating among 
themselves in regard to a new phenomenon. 

The sunlight lay in dazzling patches on beds of bright 
flowers, on the snowy white curtains at the open windows 
of the wards of the Woman's Hospital — the Frauenklinik 
of the State University of Freiburg, in Baden. It rested 
like a spotlight on a hurrying group of doctors encased in 
long white linen coats that flew starched tails like pen- 
nants, their chief striding ahead of them in vehement dis- 
course which they were expected to catch on the wing. 

It did not escape the attention of the convalescent 
mothers that the chief was not in his sunniest mood, in 
spite of the June day and the sympathetic anxiety to please 
noticeable in the faces of the breathless staff. Their dizzy- 
ingly white procession whipped sharply into the great 

1 



2 AUTHENTIC TWILIGHT SLEEP 

doorway of the dilapidated grey wing which contained the 
lecture rooms, operating theatre, and private wards, and 
then disappeared. 

The convalescent mothers, mostly patients of the third 
and fourth class wards, resumed their speculation on a 
phenomenon revolutionary to the laws of nature and ortho- 
doxy, in which they had been involved. 

The topic under discussion was that of having one's 
baby, under any or all complications, without pain. And 
these were the old guard of the free wards, the "multi- 
parse," who had had babies in the Frauenklinik even 
before the old chief died and the new chief had been sum- 
moned to replace him. The new chief had brought new 
ideas, which he was developing with their co-operation, to 
the great comfort of their persons. But the topic was none 
the less still under discussion, and each new convalescent 
added her contribution to it. 

In the little world of European obstetrics the topic was 
equally under discussion. 

The Frauenklinik was the centre of a great controversy 
comparable only to that which had raged round the work 
of Sir James Young Simpson in England in 1848. The 
obstetricians of Berlin were determined that the Freiburg 
experiment in painless childbirth should fail. The first 
university of Germany could not afford to let the third 
university of Germany get the credit for a new and revolu- 
tionary contribution to obstetrics, and impose on the pro- 
fession a method involving infinite work and trouble for 
the obstetrician. 

Professor Bernhard Kronig, the new head of the depart- 
ment of gynecology and obstetrics at the Freiburg Univer- 



THE EKAUENKLINIK : A DAY IN JUNE 3 

sity, was the comparatively young man who had had the 
daring to challenge Berlin with the result of his experi- 
ences in painless childbirth. The exhaustive report pre- 
pared by his assistant, Dr. Carl Gauss, in 1906, was reap- 
ing a whirlwind of professional anathema, because it was 
so scientifically convincing that it defied legitimate attack. 
Kronig had followed up this cold scientific report by an 
unforgettable appeal to his colleagues to give due impor- 
tance to the relief of pain. He had already disturbed the 
smooth course of obstetrical debates by opposing to the 
first principle of modern obstetrics, which enjoined saving 
the mother, if need be, at the expense of the child, his 
notable amendment that the obstetrician should make him- 
self competent to save the mother and the child. His, "I 
will save the mother and the child," had rung through the 
medical schools, causing a preliminary consternation. 
Upon the heels of it, the reports from his Freiburg clinic 
and his addresses to the various obstetrical congresses 
showed him a young advocate for humanity with a soul on 
fire. Upon this youth Berlin felt under the necessity of 
using its bitterest rod of dicipline ; upon this fire it poured 
ridicule and contempt. 

"Time will tell," was the sententious declaration of the 
great Bumm through his mouthpiece, Hocheisen. Hochei- 
sen meant that the Freiburg experiment would be killed 
by adverse opinion, since it was settled that it should not 
have the seal of approval of Berlin. 

Time did tell, though not in the way implied by young 
Hocheisen and the obstetricians of Berlin. 

But on that clear June day, in the half-mediaeval city 
of the Black Forest which is Freiburg, time had as yet 



4 AUTHENTIC TWILIGHT SLEEP 

brought nothing better than a malicious campaign of per- 
sonal innuendo against the innovator of Freiburg's "Dam- 
merschlaf," which was the name given to the new method 
for abolishing suffering in childbirth. 

Outraged in his personal honour by sneers against what 
was termed his "propaganda" — for he had consented to 
talk to the women of Freiburg themselves about what was 
being done at the clinic where a number of them had been 
private patients — the chief of the Frauenklinik was in no 
easy mood either for his sedulous staff or for the poten- 
tial patients who were gathering outside his grey little 
consulting room as the afternoon consultation hour ap- 
proached. 

The first of these tentative inquirers was a timid young 
German woman. She afterward reported her interview 
as something like this : 

"I-am-expecting-my-baby-this-month, Herr Professor — 
and-my-last-baby-thirty-three-hours - of- such-colossal-suffer- 
ing-was-that-I-thought-I-would-come-and-you-would-to-have 
the-Damm erschlaf -advise-me-so- 1- too-can-a-painless-child- 
geborn." 

If it hurt the professor to extinguish this flicker of hope 
in a frightened heart, he gave no sign of it, but said : "I 
am very sorry. I cannot advise you." 

During the five minutes which her courage lasted, his 
formula never varied. He was very sorry, but he could 
not advise her, he could advise nobody, to take the Dam- 
merschlaf. He walked continually the length of the 
gloomy little bare-walled cage with the grated windows 
that was his office, and she presently found herself shoved 
with a firm but friendly hand into the arms of the at- 



THE FEAUENKLINIK: A DAY IN JUNE 5 

tendant head nurse. He was not conducting a propa- 
ganda, and it was a matter of no concern to him one way 
or the other who took the Dammerschlaf. He was in his 
consulting room to examine patients, not to make up their 
minds for them. 

The next was the unusual patient. 

The professor's face cleared with relief at sight of her. 
She was one of those people, like himself, who know their 
own minds and have eager convictions. She had come to 
him a month before, declaring her intention of having the 
Dammerschlaf, had selected her room, her nurse, etc., and 
then had gone away to return in June. 

She was the first American patient to apply at the 
Frauenklinik for Twilight Sleep. 

Years were to pass before one of her women friends 
was actually to cross the ocean to follow her example. 

Her first "painless child" was born that June day at 
the clinic, in the shabby old maternity wing of the hos- 
pital. 

Two years later she was again at the clinic, for another 
painless child. 

She found great changes. 

She found a beautiful building added on to the old 
wing; an augmented staff, a number of birth-rooms espe- 
cially designed for the delicate requirements of Dam- 
merschlaf, sunny private wards for the convalescents, and 
a nursery. 

The Grand Duchy of Baden had recognised the impor- 
tance of the Dammerschlaf work; had seen the need of a 
specially fitted hospital, and, since Dammerschlaf could 
be properly administered only in a hospital, the need of 



6 'AUTHENTIC TWILIGHT SLEEP 

fitting up such a hospital as could be comfortably resorted 
to by the sensitive women of the nobility. So there was a 
new hospital adjoining the old. 

A year later the American patient returned for her 
third painless child. The consistency of her enthusiasm 
over these three events began to have its effect in America. 
Freiburg was now a on the map" among her friends, as 
the place where one went to a German hospital and had 
one's baby without pain. 

She was now called upon to explain the painless 
method. 

"You are put to sleep," she explained, "the moment that 
real pains begin. The last thing you remember is the 
second hypodermic injection. When you wake up, the 
nurse brings you your baby, all dressed, snuggled in his 
pillow." 

Asked about the nature of the drug used to induce the 
peculiar sleep which obliterates memory but leaves the 
muscular functions unimpaired, her information was less 
specific. 

It was only lately rediscovered, apparently, the drug 
which produced this result. Its name was scopolamin. 
It was used in very minute doses over the whole period of 
birth at intervals determined by the patient's condition 
of consciousness. With the initial injection there was 
combined a very small and harmless dose of morphin whose 
effect lasted over a period of some hours. The scopolamin 
had shown the characteristic of offsetting the undesirable 
features of morphin while it accentuated its influence on 
the thinking brain. The influence of scopolamin passed 
off quickly, and was without unpleasant after-effects. 



THE FKAUENKLIETK: A DAY IN JUNE 7 

Asked about the after-effect of the drug on the child, 
she declared that it had absolutely no after-effects on the 
child, and instanced her own healthy babies. And she 
described the marvellous rapid convalescence of the mother 
which is a feature of the painless confinement. More 
mothers, she added, were able to nurse their babies. 

The history of the birth of this first American patient's 
first Freiburg baby brings out a number of points that 
illustrate the stage of development which the Freiburg 
method had reached in 1908, when its humane and scien- 
tific value was already well proved by the two doctors who 
had worked it out over a period of three years and about 
fifteen hundred cases, in the old maternity wards, without 
the advantage of suitable environment. 

Even in the private wards, at that time, it was not 99 
per cent, perfect, as it is to-day at Freiburg. Perfect 
Dammerschlaf was not then an assured thing for every 
patient. The furnishing of the perfect environment and 
the adaptation of the dosage to the individual patient were 
still to come. Still to come, also, was the perfected stable 
solution of the drug. Professor Straub, of the pharmaco- 
logical department of the University, was working on a 
preservative which has since taken its place in the pharma- 
copoeia: Scopolamin haltbar is the name of the Straub 
preparation. 

The first Twilight baby born to an American woman 
was nevertheless a miracle to its mother, who judged of 
her subjective experience by comparison with earlier 
births; it was not a miracle to the doctors, who had had 
completer successes with other cases. 

It was a very quick birth, in which very slight pains 



8 AUTHENTIC TWILIGHT SLEEP 

became hard, severe pains rather unexpectedly, before the 
patient received her first hypodermic injection of scopol- 
amin-morphin. The violence of the pains interfered with 
the full action of the drag, so that the patient remembered 
some pain, and a sense of being bound and helpless. Later, 
when for an examination or some such reason, a bright 
light was thrown upon her, she woke to clear connected 
thinking, and complained to the doctors that she was 
awake. They stared at her, as she expresses it, glassily; 
and it seemed to her something like fifteen minutes before 
they appreciated that her thoughts were coherent, and that 
her mind was genuinely awake. Then a mask was put 
over her face to shield the sense of vision. For it was the 
sense of vision, startled by the bright light, which had 
awakened the sense of pain. With the light shielded from 
her eyes, she went immediately into perfect Dammer- 
schlaf, and has no further memories of the birth. The 
birth took six hours from the time of the first injection. 

Wben this patient's next Dammerschlaf baby was born, 
the new hospital was already completed. Apprehending 
another quick birth, she had taken the precaution of spend- 
ing the night at the clinic during the last few weeks of 
pregnancy, as the quaint old Hohenzollern Hotel at which 
she stopped was quite at the other end of the city. She 
was therefore already safely established in the big blue 
birth-room — the boy-baby room — when she felt the first 
premonitory backache that precedes the pains. Without 
waiting for any pains to set in, she was at once given her 
first injection of scopolamin-morphin, and in the course 
of half an hour she went to sleep. The birth was of the 
same duration, and the pains were of the same hard char- 



THE FKAUENKLINIK : A DAY IN JUNE 9 

acter. But of the entire course of labour and delivery she 
retains not a trace of a memory. The method had worked 
in all its perfection, owing to ideal environment and the 
thorough understanding, by the doctors, of the patient's 
temperament, and its reaction to the drug. 

Her first Dammerschlaf baby, although not a perfect 
Dammerschlaf, had been so personally satisfactory to the 
patient in contrast to other, earlier confinements, that she 
came back for a second ; the second brought her back for a 
third. 

A description of her perfect Twilight Sleep can never 
be given subjectively by the patient. She can report only 
on the imperfect ones. 

In the clinic reports, this light sleep is compared with a 
condition familiar to alienists which in Germany they call 
Dammerschlaf; the Freiburg sleep is called "artificial" 
Dammerschlaf, indicating that the physician has induced 
the condition, familiar to alienists, in which, while appar- 
ently awake, and certainly in possession of his muscular 
faculties, the patient's mind is entirely aloof from all that 
is going on around him. Pedagogues are familiar with 
the same condition in children. The absence of the child's 
mind from his task is a familiar phenomenon of the school- 
room. Booth Tarkington has described it inimitably in 
one of his Penrod stories. Just as a sharp word will draw 
the child's abstracted mind back to consciousness of its 
environment and its task, so a sharp appeal to the senses 
of hearing or sight will draw the "artificial" Dammer- 
schlaf patient back into consciousness. 

The lay man or woman may not give a personally ob- 
served description of another's Dammerschlaf. Even vis- 



10 AUTHENTIC TWILIGHT SLEEP 

iting physicians have been unable, owing to the prejudice 
of the average private patient, to observe the Dammer- 
schlaf in its ideal environment in the first class ward. 

But a sort of composite snapshot may be made up from 
the too technical reports of a long process, and from the 
notes that both as patient and as outside observer we have 
gathered during the many months spent at Freiburg. The 
patient usually has recollection only of going to sleep and 
of the curious subjective experience of waking up in a 
still dreaming state; but she hears, during her convales- 
cence, many a quaint anecdote of her sleep, if she has been 
talkative, from her nurse and doctor, and some of these we 
may string together here, confident that any one who has 
assisted at an ordinary birth over a long period of hours 
will be able fully to appreciate what a very different thing 
a birth under Dammerschlaf really is, not only for the 
patient but for the watching doctor. 

The patient may have had her husband or other family 
representative with her in the darkened birth-room. But 
with the entrance of the nurse bringing the little white 
bottle of sleep, all disturbing elements must be withdrawn ; 
and what element more disturbing than a close personal tie 
with the world of personal consciousness can there be? 
In the quiet stir of the nurse's entrance, therefore, the 
family unobtrusively goes out, usually unnoticed by the 
patient, who is now experiencing the first of her real pains 
and is either expressing them if she is emotional, or re- 
pressing their expression if she is stoical, and is being re- 
assured in either case and soothed by the nurse. The 
doctor who is to direct the sleep has come in, examined the 
position and heart-beat of the child, and has withdrawn, 



THE FBATJENKLINIK: A DAY I1ST JUNE 11 

to return after the second injection shall have been given, 
and has begun to take effect. 

The suffering of labor increases, combating the drowsi- 
ness of the patient, who is still conscious of the pains, and 
may ask for the next injection, and also for a drink of 
water, as the drug quickly makes her thirsty. 

With the second injection the sleep deepens. She makes 
no response to remarks or questions, and her regular 
breathing speaks for itself. The necessary disagreeable 
preparations for the birth may be made without disturb- 
ing her, and some women express great thankfulness for 
this escape from these sights and sensations. 

Later, the doctor comes in ? feels her pains. She appears 
to perceive his touch, and herself comments on the pain 
as if in full consciousness; but while his hand is still on 
the relaxing muscle her expression has changed to one of 
childish interest, and she says : "It's all right now. The 
dog that was here just took it out of the room." 

The incompatibility of ideas here expressed shows a 
perfect condition of amnesia or instantaneous forgetful- 
ness, and there is as yet no need of another injection. 

Direct questioning to evoke such an expression some- 
times arouses impatience if not alert consciousness, and is 
likely to fail utterly with stupid patients or highly nervous 
ones; it has therefore to be used with great tact. But 
whether directly or indirectly applied, this test is the most 
important of all the means of checking up the condition of 
amnesia. 

The labour progresses. The patient may not be making 
her voluntary share of it, however. Before suggesting 
this to her, the doctor may wish to make sure that her 



12 AUTHENTIC TWILIGHT SLEEP 

mind is still fully clouded. He offers her the whimsical 
pastime of imitating him in quickly putting the tips of her 
fingers together. Her vaguely restless hands make a flut- 
tering effort at obedience, but with such an inadequate 
result that the motion she makes is like the ripple that we 
have seen stir the muscles of a dog's legs when, lying 
before the fire, he dreams of running. This shows a loco- 
motor ataxia which is characteristic of the condition of 
clouded consciousness the doctor wishes indicated. 

He then asks her to make more effort with the pains — 
to push harder — and this, curiously enough, her lower 
mind controls perfectly, as it is intimately bound up with 
the involuntary birth process going on throughout. 

The labour has reached a stage where the pains come 
without intermission, and the doctor settles down for that 
continuous observation which alone guarantees the patient 
uninterrupted sleep. The nurse comes and goes. If it is 
a night case, and the night advanced, the doctor may lie 
down on the couch and drowse until such a time as there 
is need of examining the progress of the labour or there 
seems need of a new injection. 

Facial expressions of pain have increased, and exclama- 
tions and moans and cries, according to the emotional 
habits of the patient. It is some time since the last injec- 
tion. The doctor ventures a direct question. Knowing 
very well that it is barely fifteen minutes since she was 
examined, he asks : "Have I examined you since I came 
in?" 

She replies : "I have been in the linen closet getting a 
fresh pillowcase for Sister M." 

She has already forgotten the question put to her. 



THE FKAUEJSTKLINIK: A DAY IN JUNE 13 

The internal examination just referred to is made with 
as little disturbance of the patient as possible. The sense 
of touch is guarded always; the sense of pain is the last 
to be aroused, and can only be indirectly approached 
through the other senses. Sometimes these other senses are 
awakened for a second, leaving impressions which Gauss 
has termed "memory islands." Unimportant in them- 
selves, he is nevertheless emphatic about the importance 
of avoiding their occurrence by the closest watching; for 
a succession of two or three over a long period of hours 
may appear to bridge the sleep and produce in the patient's 
mind a sense of continuity of consciousness. Births with 
even one such recollection are classified as "partial" Dam- 
merschlaf. In spite of the scientific prejudice, they are 
of very little importance to the mother, who as often as 
not finds her fragments of memory amusing. Their dan- 
ger is of being too acute and of rousing the apperception 
of pain. 

After several injections, a sucking motion of the lips as 
in drinking, showing thirst, is almost as frequent as the 
frown of pain ; but the doctor's examination of the pupil 
shows no dilatation from the pain, and this absence of 
dilatation is a sign of the deepest sleep. The patient may 
turn, move in discomfort, or cry out and twitch her numb 
fingers constantly, but with all this restlessness never 
ceases in her labour. 

At the delivery stage, when the lights have to be turned 
on and there are several people in the room, the senses 
of sight and hearing need special protection. A mask is 
put over the eyes, and cotton dipped in oil is put in the 
ears as "antiphones." 



14 AUTHENTIC TWILIGHT SLEEP 

She rises, perhaps, almost out of bed with the tremen- 
dous muscular lift of the expulsory effort, and then sinks 
back with a great sigh. Sometimes she expresses great in- 
terest in the baby ; asks if it is a boy or a girl, etc. ; but of 
this she retains afterwards no memory, any more than of 
her participation in the birth or the after-birth. Some- 
times she has even offered to get up so that the nurses can 
more easily make her bed over. But, the birth done with, 
she relaxes into a profound and refreshing sleep from 
which she wakes, several hours later, to a great amaze- 
ment, "incredulous that it is her own living child that is 
put in her arms." 

Some time during that first day after, or during that 
first day, she is given some simple bed exercises, which she 
is surprised to find are painless; and these exercises are 
repeated every day during the lying-in. 

Of the lying-in itself, there is no great objective evi- 
dence. 

The patient who became a mother in the small hours of 
the night wakes refreshed. She may wake while she is 
still in the birth-room, on the somewhat unyielding bed on 
which she was confined, or she may have been transferred 
while still asleep to the ward or the private room. If to 
the ward, she will wake to find her baby in the crib at the 
foot of her bed. But whether the private patient wake in 
the birth-room or in her own room, the first thing she 
sees is the muslin-curtained crib, and her baby lifted 
from it and put into her arms. 

Coffee and rolls are brought in for breakfast if that has 
been her morning custom. She sits up and breakfasts. 
At ten o'clock comes a light refreshment, such as milk or 




Courtesy M lss Alice Bouyhton 

Mrs. Cecil Stewart was the second American woman to go to 
Freiburg for her baby. 



THE FKAUEKKLIETK: A DAY IIsT JUKE 15 

beer and crackers. At noon a hearty dinner which may 
well happen to include two or three meats and vegetables ; 
pork, perhaps, sausages, cabbages, cauliflower, brussels 
sprouts, dessert. At three-thirty the coffee or tea hour 
comes round again. In the evening a light supper is of- 
fered ; more soup, meat, omelette, vegetables, and dessert. 
It is held, perhaps rightly, that the making of milk should 
be induced by the same nourishing food that was partaken 
of during pregnancy, and that no food to which the child 
was no stranger during those months will be deleterious to 
him in the mother's milk. 

Some time during that day, also, the mother gets out of 
bed and stands on her own feet, with the protective arm 
of the nurse to reassure her. One adventurous patient, 
who has had two Freiburg babies, immediately dressed and 
went out to find social companionship in the Liegehalle, 
or rest room, where the steamer chairs overlook the garden 
and the sunset. Every day the time spent out of bed 
lengthens; by the fourth day it is not unusual to see a 
Frauenklinik mother out driving, and by the end of the 
week returning a reasonable number of calls of congratu- 
lation. The conserved nervous energy due to painlessness 
goes into the milk, as often as not, and into the readiness 
with which the woman returns to the routine of domestic 
life. She is, at the end of ten days, in her normal, and 
sometimes in better than her normal, condition. 

It was this miracle of a painless birth followed by a 
miraculous recovery that Freiburg had to offer, on that 
June day when the first American mother entered it as a 
patient who had had ^ve babies, none of them painless, to 
have her first painless child. 



16 AUTHENTIC TWILIGHT SLEEP 

And such is, objectively, the method which, from the 
time of its first application to a human mother, has been 
developed to its point of highest perfection at Freiburg, 
in response to the demand of the women who, endorsing it 
among themselves, carried the purely local knowledge of 
it abroad. But it remained a local method, and it became 
a familiar event, at the Klinik, to see a Dammerschlaf 
mother return from far countries for another confinement. 

The amount of time and trouble for the staff which 
such a method involved is obvious; yet this time and this 
trouble continued to be freely offered, although the method 
was gaining little scientific recognition. 

The statistical data grew; studies of special phases of 
the birth process under Dammerschlaf were made and 
filed; but little by little the subject of Dammerschlaf was 
subordinated in the reports from Professor Kronig's clinic, 
in favour of the subject of radio-therapy in which his col- 
leagues shared his interest. The last Dammerschlaf re- 
port on a study of 3,000 cases was never even published, 
though it may be pieced together from excerpts in German 
obstetrical journals which covered the congress at which 
the address was read. A few Dammerschlaf-trained men 
went out from the Klinik, and continued to practise it in 
other cities; one or two country practitioners adopted it, 
as their practice was small, and they were humane in 
their obstetrical work. 

The ban placed on the method by the great school of 
Berlin had effectively localised the practice of Dammer- 
schlaf. 

But its employment in the Erauenklinik could not die 
out while the demand for it continued to fill the wards with 



THE FKAUENKLIETK : A DAY IN JUNE 17 

patients who wanted it ; natives of Baden, and foreigners 
who heard of it by word of mouth and who came to Frei- 
burg to get what they could not obtain elsewhere : a pain- 
less child and a miraculous recovery from childbirth. 

Perhaps it is not too much to say that the custodians 
of this great and revolutionary discovery of science were 
the successive little groups of convalescent mothers who 
gossiped in the garden of the Frauenklinik, on sunny 
days, or who compared their babies in the nursery above ; 
just as it may be that the influence of the Freiburg method 
might never have made itself felt in obstetrics in America 
but for the arrival at Professor Kronig's clinic, that June 
day in 1908, of the unusual patient who was to carry its 
message across the Atlantic. 



CHAPTEK II 

Prof. Kronig's Talk to the Women of Freiburg 

Professor Kronig's talk to the women of Freiburg has 
passed into tradition, in Freiburg. The spirit of the tra- 
dition lives, but of the letter it is impossible to find any 
but the most scattered notes. 

It had seemed to us that if we could reproduce this 
talk, before the larger audience of the magazine-reading 
women of the United States, the argument for painless 
childbirth would be presented to them by the man who 
had fought for it. 

Ultimately we found, not the notes of this talk, but 
Professor Kronig's talk to his students, which incor- 
porated the same statements, a little less colloquially illus- 
trated. This, together with interviews with American and 
Freiburg mothers, made what seemed to us a simple pres- 
entation of the work at Freiburg. The necessary trans- 
lations were made in the two months which preceded the 
birth of "Peter" Boyd ; the first draft of the article was 
made during his mother's convalescence ; the last draft, as 
one of us vividly remembers, was revised in the twilight of 
the birth-room during the approaching birth of another 
American baby, afterwards known as the "Spaniard," 
from Lerida, in Spain. 

18 



PKOF. KKONIG'S TALK TO WOMEN 19 

The colour of our daily lives painted the picture. It 
was inevitable that sentiment dominated it; we were not 
scientists, but women assisting at the most overwhelm- 
ingly emotional consummation in women's lives. The 
ridicule which the medical press afterwards visited on us 
as sentimentalists seemed lacking in worldly wisdom. For 
the virulence of the criticisms showed that our story had 
gone home. 

Freiburg is a small place. A walk from one extreme 
end of its venerable main artery of traffic to the other will 
take a leisurely ten minutes. Two mountains rise up at 
either end of the town. One is called the Schlossberg, and 
the other is called the Bromberg. The ascent of these 
mountains is the perpetual exercise of all Freiburg that 
does not go farther afoot, and you will scarcely find a 
woman in Freiburg who has not climbed them. They con- 
stitute, to a woman, a known measure of effort, just as a 
teaspoonful constitutes a known measure of quantity. 

So, when a number of Freiburg mothers asked Pro- 
fessor Kronig to explain to them why it is becoming un- 
scientific to allow pain in confinement, he explained in this 
way: he said that the actual normal muscular effort in- 
volved in bringing a baby into the world corresponds to a 
climb up the Schlossberg. But, for the modern woman of 
highly complex nervous organisation, the muscular effort 
is complicated with so much pain that often the pain 
itself becomes a factor of serious interference with the 
birth. And he compared the mother's muscular effort to 
bring her baby into the world in these conditions to a 
woman who might be obliged to climb the Schlossberg 
with a sharp nail in her foot. 



20 AUTHENTIC TWILIGHT SLEEP 

This legend of the Schlossberg, together with the state- 
ment that no woman should have more children than she 
is physically fit for, and personally inclined to bear — a 
blow at classic German tradition which brought the wrath 
of the orthodox down upon him — were all that Freiburg 
women could quote of Professor Kronig's talk to the 
women of Freiburg. 

The talk came about through an appeal made to Pro- 
fessor Kronig by the wives of the university faculty. It 
was entirely informal, and, like many things which are 
the harbingers of great changes, seemed too purely a mat- 
ter of friendly interest to be taken seriously. Some twelve 
of them merely asked to be received in the clinic lecture 
room, during some free half-hour, to have the points at 
issue in the Berlin-Freiburg controversy cleared up. This 
talk, owing to the universal appeal which the subject of 
painless childbirth invariably makes, no matter where it 
is broached, developed into six talks that led one to the 
other, while the audience of Freiburg mothers grew from 
the original jury number to four hundred. 

Four hundred women were a large percentage of the 
socially-minded. These retired into their various spheres 
of ordinary activity, with a message that comforted, and 
a message that rankled. The humanity which they ap- 
plauded when it put its whole scientific reputation behind 
its endorsement for painless childbirth was not so unani- 
mously applauded when it stood out fearlessly for the 
limitation of the family; for the sparing of motherhood 
from the exhaustion and brutalisation of unrestrained and 
excessive bearing. The furnishing of soldiers for the 



PEOF. KKONIG'S TALK TO WOMEN 21 

Kaiser's army, then as now, was the shibboleth of German 
motherhood. 

The notes taken by one of his women listeners show 
that apart from one or two colloquial illustrations he 
addressed them very much as he did his students a few 
years later when the Dammerschlaf had become the rou- 
tine practice of the Erauenklinik and men were learning 
it as part of their obstetrical work. 

This address was published in Leipsic in 1908. 

It required no great research to come upon a copy of it 
at a medical bookseller's. It was, needless to say, written 
in German and required the intervention of a translator. 

To one of us, at least, Krbnig, 1908 is not merely a 
brown-paper-covered pamphlet. It is four flights of stairs 
in the echoing darkness of a half -empty business building 
on Kaiserstrasse, and the gaunt classroom of the English 
instructor in the Berlitz School. Up these stairs, daily, 
for the hour's dictation, came the journalist-who-was-to- . 
have-a-painless-child, and transcribed the great German 
obstetrician's message to his time. 

With Kronig no farther away than the flight of a ball, 
with most of the four hundred women who had heard the 
lectures passing, day in and day out, on the shopping 
street, herself handicapped by the lack of modern German, 
the journalist might have been the amanuensis of an 
Egyptologist deciphering hieroglyphics from a tomb, in- 
stead of the recently buried treasures of obstetrical science 
from the contemporary German medical press. 

Like a discovery, that 1908 report; and her heart 
burned within her. 

As far as she then knew, it was the first scientific rec- 



22 AUTHENTIC TWILIGHT SLEEP 

ognition of the injuriousness of pain in childbirth/ al- 
though with the eyes of a person who was not scientific 
she had seen the injuriousness of pain in childbirth ex- 
emplified in her own family. 

She was to find that it was only one of many such state- 
ments from obstetricians of international reputation, and 
that many of the earlier ones were much more specific. 
But in its spontaneity, its sensitiveness, and the eloquence 
of its direct appeal to the younger generation who might 
have the opportunity in obstetrics for which he was still 
fighting, Kronig's enjoining on his young students to take 
account of pain as a pathological element in childbirth was 
peculiarly impressive. 

"Of late," said Professor Kronig, a the demand made of 
us obstetricians to diminish or abolish suffering during 
delivery has become more and more emphatic. The mod- 
ern woman, on whose nervous system nowadays quite other 
demands are made than was formerly the case, responds 
to the stimulus of severe pain more rapidly with nervous 
exhaustion and paralysis of the will to carry the labour to 
a conclusion. The sensitiveness of those who carry on 
hard mental work is much greater than that of those who 
earn their living by manual labour. k 

"As a consequence of this nervous exhaustion, we see 
that precisely in the case of mothers of the better class the 
use of the forceps has increased to an alarming extent, and 
this where there is no structural need of forceps. 

"When one goes into the records of the cases of women 
like these concerning their previous confinements, one is 
almost driven to the conclusion that spontaneous birth is, 
in their cases, practically impossible. It is by no means 



PKOF. KKONIG'S TALK TO WOMEN 23 

unusual to hear that the forceps had to be used at every 
previous confinement. Neither structural difficulties nor 
muscular weakness had indicated the necessity for oper- 
ative interference. The forceps had been used simply and 
solely to shorten the pains of labour. 

"On the occasion of a meeting of the Berlin Obstetrical 
Society, it came to light that obstetricians practising in 
the best society of Berlin were obliged to use the forceps 
in nearly forty per cent, of their cases. 

"In theoretical medical instruction, the 'rescuing' for- 
ceps finds no place. In practice the conditions are differ- 
ent. 

"The cases available for obstetric study in the hospitals 
consist, for the most part, of women of no great intelli- 
gence, who earn their bread by manual labour. 

"In private practice we not infrequently have to do 
with women of nervous temperament who declare them- 
selves incapable of enduring the pains of labour to the end. 
A medical man often, in such cases, finds himself before 
the alternative either of ending the delivery operatively 
with the forceps, or of retiring in favour of another doctor. 

"If we take the trouble to sit at the bedside of women 
of some sensitiveness during the whole course of labour, 
and to observe the state of their nervous system, we are 
compelled to admit that in their case such nervous ex- 
haustion does really set in, that all power of will to hold 
out till the end of birth is paralysed. 

"I hardly believe that any one who takes the opportunity 
of observing a birth in the case of one of these women, 
from beginning to end, would afterwards agree with the 
statement that the pain of birth is a physiological pain 



24 AUTHENTIC TWILIGHT SLEEP 

which is really of advantage to the mother and must not 
be reduced. Such a statement can only be made by those 
clinicians who, having to do with too large a number of 
cases, have not taken the trouble to follow the nervous 
condition from beginning to end of labour, and who con- 
tent themselves — as indeed is necessary when working on 
a large scale at high pressure — with ascertaining occa- 
sionally how the case is going on. 

"When Steffen, on the occasion of a discussion about 
the reduction of pain in childbirth gave utterance to the 
statement, based on his experience of a large number of 
cases in the Dresden Woman's Hospital, that as a matter 
of fact he had never felt any necessity for lightening the 
pain felt by a woman in childbirth, this is only to be ex- 
plained by the fact that he was either quite callous or 
that when the screams and groans of the woman became 
too loud he left the room. 

"Acute pain at birth cannot, in the case of sensitive 
women, be termed physiological, for it frequently occasions 
a condition of severe exhaustion even after birth. 

"Any gynecologist who considers that he ought to be 
something more than merely as good an operative manipu- 
lator as possible — who thinks, that is, that he should ob- 
serve the nervous condition of the mother — will not infre- 
quently note that neurasthenic symptoms appear in im- 
mediate connection with the delivery. One is only aston- 
ished that long-continued exhaustion does not occur more 
frequently, when we realise what a sensitive woman has to 
endure during her confinement, even taking into consider- 
ation the mental impressions alone. 

"The preliminary pains are probably stood well. But 



PROF. KROJSTIG'S TALK TO WOMEN 25 

with their increasing frequency and violence the moral 
resistance breaks down. She feels her strength giving 
way, and does nothing hut beg the doctor to use the forceps 
and put an end to her agony, and longs only for the mo- 
ment when she will be released from pain by the chloro- 
form or ether. 

"If, as often enough happens in private practice, the 
forceps is used without anaesthetic, because the doctor is 
afraid to trust the continued administration of the anaes- 
thetic to an inexperienced helper, then, in addition to the 
ordinary pains of birth, the woman has the pain of the 
operation. The loss of blood, especially in the case of a 
first child, is relatively great, and bodily exhaustion is 
thus added to mental. 

"It is true that robust women can stand all this with- 
out consequent injury to their nervous system; but it is 
equally undeniable that, if there is the slightest inclina- 
tion to a neuropathic condition, such severe bodily and 
psychical injury is the cause of a long period of exhaus- 
tion." 

It seems to be a fact that a man who is hypersensitive 
to pain either becomes a great doctor, or else does not enter 
that profession. 

At the bedside the average practitioner called to a con- 
finement meets its frequently tragic emergencies with a 
kind of fatalistic philosophy. His bad cases usually come 
in quick succession, after which he has some months dur- 
ing which the terror and despair of the bad period efface 
themselves, and he once more breathes freely, and re- 
assures the prospective mother and makes light of her ap- 



26 AUTHENTIC TWILIGHT SLEEP 

proaching ordeal. He rests in the faith that Nature, not 
science, is the great obstetrician: "Let Nature take care 
of itself." 

In fact, the recognition of the pain element in child- 
birth is systematically subordinated to the joy element 
which in the majority of cases follows it. A young trained 
nurse once said that she chose obstetrical work instead of 
"sick" nursing, because everybody is so happy in the 
family where there is a new baby. ■ 

That the joy of the new baby is frequently the prelude 
to its mother's lingering invalidism for a few months or a 
year is accepted as a part of God's will, and the invalid- 
ism meekly borne. Earely is it laid to poor obstetrics; 
still more rarely to the pain element in the confinement 
in which the patient showed grit for which she was warmly 
praised by the attending practitioner; that "biting back 
the cry of the pain in self-scorn" that is described by 
Mrs. Browning "when the man child is born." 

It took a very imaginative scientist to discover that 
this pain of travail so abundantly testified to in literature 
was a profoundly expressive literary symbol, and a great 
test of stoicism; but a most destructive adjunct to the 
physiological phenomenon of child-bearing. 

In the middle of the last century a scientist with the 
eloquence of Kronig for the first time puts himself on 
record in medical literature. James Young Simpson, the 
first supporter of painless birth, characterises pain in 
childbirth as not merely a disagreeable accompaniment of 
birth, but as "a dangerous and a destructive one." 

From this time down to the present, pain is acknowl- 
edged by the obstetrician; but it is acknowledged mostly 



PKOF. KKONIG'S TALK TO WOMEN 27 

to belittle it. For one Simpson there are several Steffens 
of Dresden, just referred to by Kronig. Steffen is quoted 
in another place as "knowing no more pleasing sight than 
that of a strong, healthy woman giving birth to a large 
first child in strong and painful birth pangs." 

"There is too much said about this pain of childbirth," 
declares an American obstetrician. "You ask any woman 
who has had a child, and she'll tell you there's nothing to 
it. I've never observed that the painfulness of the first 
labour kept a woman from having a second." 

"Yes," assents another thoughtfully; "a woman with 
plenty of grit would always rather carry it through with- 
out anaesthesia." 

Such men seem to wash their hands of the destructive 
nervous shock that accompanies the grit. They see the 
pain. Their statements show it ; but they persist in taking 
it lightly and in speaking of it flippantly. 

It is this type of practitioner whom the French obstetri- 
cian Audebert had in mind when he enumerated amongst 
the advantages of painless birth that it prevents the bru- 
talising of the obstetrician by the daily observation of 
agony. He adds that it spares the sensitive obstetrician 
the nervous strain which the sight of unrelieved agony 
puts on him. 

How serious this pain really is has been quite forcibly 
set down in words by Simpson. This inventor of chloro- 
form lived in a day when surgery without anaesthesia was 
as familiar a sight as it is fortunately rare to-day. So, 
knowing that whereof he spoke, he said : "The total sum 
of actual pain attendant upon natural labour is as great if 



28 AUTHENTIC TWILIGHT SLEEP 

not greater than that attendant upon most surgical oper- 
ations." 

From the fifteenth century come the quaint words of 
the monk physician Heironymus, who could grasp and 
sympathise with the pain he was helpless to relieve. 
"Mulier in partu maximos et fere intolerabiles sustinet 
dolores." (Woman in childbed has to endure the acutest — 
nay, almost intolerable — sufferings.) 

One hears occasionally of a painless birth that has been 
naturally painless. Most of this natural painlessness is 
traced by the physician to pathological conditions ; among 
them paraplegia, tabes, myelitis, coma of puerperal con- 
vulsions, placenta prsevia, and oedema of the vulva. Earer 
still are the cases of a few laxly built women, mostly those 
who have borne more than one child. There sometimes 
arrives a time in a painful birth when the capacity for 
pain seems to be exhausted; this painlessness is followed 
by the same exhaustion and shock as a painful birth, and 
while the mother takes it lightly, saying that the pain was 
as nothing to the joy that remained, she is none the less 
an invalid for some months. 

A few obstetricians believe that pain in childbirth has 
a physiological function. Its practical usefulness to the 
physician has been evident from the way that the older 
school has admitted that it guided its forceps by the cries 
of pain. But setting aside this not very professional use, 
which is somewhat like the dentist, the only serious argu- 
ment ever advanced for the physiological value of pain is 
that lusty cries increase the oxygenation of the maternal 
and foetal blood ; with the cessation of these cries there is 
lessened air admitted to the lungs at each inspiration. 



PKOF. KKONIG'S TALK TO WOMEN 29 

In the case of Kronig's method the cries, it may be 
pointed out, do not entirely cease, instantaneous forget- 
fulness, not painlessness, being the Dammerschlaf condi- 
tion. 

But this case for the aeration of the blood by pain seems 
almost farcical beside the case for the destruction of 
vitality by pain, for the classic argument in medicine 
against pain is that it exhausts the principle of life. 

And this is no less true of the pain of childbirth than 
of any other as the exhaustion following childbirth in pain 
is as great as that following any other form of pain. 

"To many patients/' said Charles Kidd in 1860, "there 
is an amount of suffering and pain in childbirth, attended 
with a sacrifice of vital force that we cannot estimate suf- 
ficiently. By artificial painlessness this nerve force is 
saved, and the patient enabled to resist the causes of fever 
and inflammation." 

This shows the tremendous importance of removing the 
weakening element of pain in pathological cases. 

But pain itself brings a pathological element into nor- 
mal birth. It is the nail in the shoe that Kronig described 
so vividly to the women of Freiburg. That is, it is unde- 
sirable, not only on humanitarian but on scientific grounds. 
It interferes with the progress of the birth. 

Kronig's method was taken up in America by a few 
obstetricians, and it is referred to among them as Hyoscin 
Sleep. This was in the days, it must be said, when the 
inferiority of hyoscin, a drug of the same family, 
to the pure scopolamin was not known. In one of 
the most illuminating reports that have been made on 
the subject, "The Hyoscin Sleep," by W. H. Birchmore, 



30 AUTHENTIC TWILIGHT SLEEP 

the ways in which pain may be a handicap to a 
birth are vividly brought out. Birchmore's great idea is 
that obstetrics is handicapped by the persisting pain ele- 
ment, and that until pain has been artificially eliminated 
it can never take its place among the highly developed 
medical sciences. He hails the hyoscin sleep as "that on 
which the improvement in obstetrics for which we have all 
been waiting may be based." He shows you how pain is 
an impediment by a series of observations on a series of 
painless births. "The physicians watching these births 
noticed the steady, slowly increasing and tremendous force 
exerted by the abdominal muscles. They observed with 
astonishment the helpful and purposeful positions that 
the women took, though soundly sleeping, in order to make 
the best possible use of their muscles. One physician who 
had attended many labours said he had never seen any- 
thing like it before. Another experienced obstetrician 
looked on in wonder. He remarked afterward : 'It was as 
if I had seen the natural action of a woman in labour for 
the first time.' " 

The convulsive and irregular pains which cause perineal 
rupture and other injuries were entirely lacking, and in 
their place were observed "a dozen small, slowly stretch- 
ing pains" that carried the birth on in orderly progress. 

Not only was the mother's voluntary action made ideal, 
but the involuntary muscular contractions were augmented 
and regularised ; for "secondary insufficiency" of the birth 
pains due to exhaustion from suffering, was not experi- 
enced. Dilatation of the birth canal was furthered, and 
relaxation of the passages prevented laceration. 

The literature on painless birth is full of these exam- 




The Sox of a Freiburg University Professor. While professional 
] etiquette forbade giving the names of men connected with Baden Uni- 
] versity, the hearty co-operation of wives and mothers in the faculty 
furnished many photographs of their Dammerschlaf children. 




£ Q 



PEOF. KKOJSTIG'S TALK TO WOMEN 31 

pies. Pain often lengthens labour by preventing the 
mother's voluntary muscular action; making her "hold 
back" instead of aiding. In some cases pain causes lacer- 
ations on account of the violent and spasmodic efforts by 
which the mother strives to end her sufferings. Exhaus- 
tion from pain often causes a cessation or slowing of the 
involuntary contractions known as secondary "insuffi- 
ciency," and makes it necessary to interfere with forceps 
or other operative measures. Another indication for for- 
ceps is where a narrow pelvis would require "waiting" to 
deliver the child naturally and the mother's suffering is 
too great to wait. It is not a mere coincidence that 
Kronig, who worked out the Dammerschlaf, is one of the 
greatest international authorities on the "waiting" method. 

In many ways the pain in such natural births as these 
injures the child also. Forceps extraction sometimes in- 
jures him, and, as Kronig has pointed out, forceps are 
to-day used more and more frequently to shorten pain. A 
birth unduly prolonged may asphyxiate him ; the mother's 
inability to wait has sometimes necessitated craniotomy, 
or her spasmodic frenzied efforts have done the baby harm. 

An American obstetrician estimates that operative fre- 
quency under artificial painlessness is only half that under 
pain. 

The exhaustion following pain in childbirth is known as 
its traumatic shock. What the elimination of this shock 
means is shown by the convalescence of Birchmore's no 
less than of the Frauenklinik mothers. For a physician 
observing some of Birchmore's mothers said to another: 
"To see them it appears a preposterous proposition to 
say that any one of them had just given birth to a child." 



32 AUTHENTIC TWILIGHT SLEEP 

Of the convalescence at Freiburg nnder the same pain- 
less method Kronig said to his students : 

"Many of you have taken advantage of the opportunity 
of seeing mothers on the day after birth out of bed, and 
you will have had the impression that by reducing the 
suffering we have not only conferred great benefit on 
mothers during delivery, but at the same time in conse- 
quence of the absence of suffering during delivery the 
condition of the mother during convalescence is very much 
better than ordinary." 

This simple and conservative statement refers to a 
phenomenon which to mothers who have borne babies out- 
side the clinic seems a miracle. Eor a woman's nerves are 
frequently so broken down by normal confinements in 
consciousness that she suffers not merely from exhaustion 
but from an acute neurasthenia, from which recovery is 
slow. 

"There can be no possible doubt," says Gauss, "that 
birth loses the character of an injurious trauma to the 
same extent as the physical suffering and the mentally 
injurious impressions are reduced or even completely 
abolished." 

If Kronig's talk to the women of Freiburg failed us, 
directly, indirectly it served us well; for the want of it 
set us to work on the fuller address of Professor Kronig 
to his students, and led us directly into that extraordinary 
report which, standing alone in the annals of obstetrics, 
had originally introduced the Dammerschlaf to the med- 
ical world: Gauss, 1906. 



CHAPTEK III 
Fear and Pain: The Psychology of Maternity 

Fear has occupied less space than pain in obstetrical 
literature. Where it has been spoken of, it has almost 
always been discussed as the "hysterical fears'' of preg- 
nancy. 

The obstetrician has been unable, or unwilling, to dis- 
tinguish between an abnormal nervous condition some- 
times observed at that time and a real nine-months' brood- 
ing on a painful and perhaps a dangerous ordeal. 

For the one sensitive obstetrician in our experience who 
out of his own observation of what childbirth was like 
said that if he were a woman he would "hang himself in 
the first month of pregnancy," we know two women who 
did actually make way with themselves, and we know 
countless numbers who avoid maternity for this reason. 

Birchmore says of scopolamin: "Until it was discov- 
ered, fear dominated pregnancy, and the pains of mater- 
nity were a horrid and uncontestable truth." 

But Krb'nig is almost alone in attempting to express the 
woman's sensations. He says in his address to his stu- 
dents : 

"The ground for the breakdown following birth is pre- 
pared even earlier during the period before birth by nu- 
merous bodily complaints — sickness, loss of appetite, and 

33 



34 AUTHENTIC TWILIGHT SLEEP 

so forth. Hypochondriacal moods, it is well known, often 
preponderate in women during pregnancy. The woman 
has heard from her friends how difficult the birth of a 
child was and how great the pain; how finally the doctor 
used the forceps and then how long puerperal fever fol- 
lowed the birth. When she herself has to give birth to a 
child the first preliminary pains are probably stood well, 
but with their increasing frequency and violence the moral 
resistance becomes exhausted. The woman feels her 
strength give way and does nothing but beg the doctor to 
use the forceps to put an end to the agony. She sees the 
preparation of the forceps, she sees the excitement in the 
expressions of her relations, and longs only for the moment 
when she will be released from pain by the chloroform or 
ether. It is true that robust women can stand all this with- 
out consequent injury to their nervous system, but it is 
equally undeniable that if there is the slightest inclination 
to a neuropathic condition such severe bodily and psychical 
injury is the cause of a long period of exhaustion." 

Kronig recognises the traumatic shock of childbirth as 
going back as far as pregnancy. 

Butler follows this traumatic shock on beyond birth 
and convalescence. He says that scopolamin "spares the 
mother the psychic traumata of childbirth. These are 
known to be the chief exciting causes of nervous and men- 
tal diseases in women besides being an important factor in 
marital unhappiness." 

Judged by some women's own experience, their subjec- 
tive traumatic shock of childbirth goes back before preg- 
nancy and poisons youth ; it extends after the first child's 
birth throughout married life. 



THE PSYCHOLOGY OF MATERNITY 35 

"I wish that one of you would come to talk to a woman 
who has come from South Africa," said the head nurse at 
the Frauenklinik. "Some one has been telling her that 
her child will be injured if she has the Dammerschlaf. 
And she has come so far to get it." 

One of the Freiburg mothers promptly volunteered. In 
the Liegehalle she met a frail-looking little woman with a 
sad face and marvellously expensive clothes whose lace 
jabots softened but could not dissimulate the fact that her 
baby would be born very soon. 

"It was a terrible trip/' admitted the stranger. "But 
it was the only thing I could think of to do. We wanted 
this baby so much, and the last birth I went through was 
a horror. I could not face going through such an ordeal 
again." 

The Freiburg mother showed the stranger over the nur- 
sery, reassured her about the safety to the child and the 
real painlessness to herself, and she went back to her 
hotel comforted. That night she took a taxi to the clinic, 
and her baby was born in the early morning. Twenty 
minutes after the birth she was awake for a while, and 
asked to see one of us who happened to be occupying an 
adjoining birth-room. 

"It was a miracle !" she cried. "I did not know a thing 
about it until they gave me the baby just now." 

Fear had dominated her pregnancy, but she had had the 
hope of Freiburg to look forward to. And now she will 
never again know that helpless fear. 

There are women who would dearly love to have a sec- 
ond child, feeling that it would be better for the first child 
to have a brother or sister; but they absolutely refuse to 



a6 AUTHENTIC TWILIGHT SLEEP 

go through another experience of childbirth. Their nerve 
has been broken exactly as has that of the engineer who 
has been in a railroad wreck. 

One young woman feels sure that fear learned through 
one terrible experience brought on a miscarriage when she 
became pregnant a second time. 

"The doctor kept saying to me: 'You mustn't worry. 
Your mental state may bring on a miscarriage. Just stop 
worrying. If you are going to lie there and worry we 
can't keep you from losing your baby.' " 

She did worry, however; she lay and wondered how 
she would live through another such ordeal as the one she 
had been through ; she had had thirty-six hours of agony, 
and then when it was seen to be impossible for the baby 
to be born alive the baby had been sacrificed. She de- 
scribes the terror with which she heard the doctor say that 
he would use the forceps. "If they had only been a little 
less cold-blooded about it," she says, with a shiver. At 
one moment, in a paroxysm of agony, she tried to throw 
herself from a window, and was caught and brought back 
to bed. When the child was finally taken, they could not 
show it to her. She has brooded over those days of useless 
torture ever since. "You get a feeling of bitterness," she 
says. "That is the only thing I can call it. You went 
through all that — and they destroyed your baby, and you 
don't dare have another." 

One woman, having gone through a like experience, 
lived in such terror of pregnancy that it preyed on her; 
one day it suddenly came to her that the only way to have 
perfect security was to drink off a good strong poison and 
end the burden of foreboding then and there. She did so. 



THE PSYCHOLOGY OF MATERNITY 37 

Another young woman, a bride of a year, was one of 
those highly organised nervous temperaments of whom 
Dr. Newell says our American society is full and of whom 
he declares that he never classes them as normal cases until 
they have proved definitely that they have nothing neuras- 
thenic about them. Upon finding herself pregnant, her 
fear took one comprehensive look at the long period of 
pregnancy with its probable outcome of a difficult birth. 
The love of her husband, the potential long and happy life 
with wealth and position to draw upon, hung for an hour 
in the balance, and fear won. She was found dead in her 
bedroom with the gas turned on like any tenant of a third- 
floor-back lodging house in an O. Henry story. 

The fear of pregnancy is a horrid and incontestable 
fact, in the experience of many women. 

The palliatives which fill the literature of hygiene for 
the pregnant mother read like the sentimental rubbish of 
mid- Victorian novels. 

Only a Simpson, a Birchmore, a Newell or a Kronig 
rises above the painful inadequacy of this sentimentalism 
with a recommendation that fear and pain be considered 
and dealt with in a spirit of scientific respect for their far- 
reaching consequences. 

We have already given the obstetricians' analysis of 
pain as an impediment to the birth process and an injury 
to the mother's health. 

For two generations in all countries, from Simpson to 
Kronig, from Ribemont-Dessaignes of Paris, to Polak of 
New York, obstetricians of insight and sympathy have 
observed the facts set down. 

The American mothers who are to-day effectively re- 



38 AUTHENTIC TWILIGHT SLEEP 

belling against birth pain do not need superior sensitive- 
ness to realise its drain on their vital forces. They have 
each her own personal experience to teach her the fear 
and the pain of childbirth. 

These are most vital in their lives. Childbirth is to the 
majority of women as certain and often as dreaded as 
death; the joy of maternity as hard-won as the joys of 
paradise. 

Medical literature deals with the pain in its physical 
effect. 

The effect on the nervous system has been given little 
study, except as it prolongs convalescence, or as it simu- 
lates uterine disease. 

Obstetricians know that pain is one of the causes of 
puerperal psychosis, the madness or delirium that some- 
times follows childbirth. But they do not know to what 
extent the nervous breakdown due to brooding fear during 
pregnancy causes these psychoses. 

Yet one form of psychosis in pregnancy is aversion for 
husband or children. 

Whatever the doctors do not know about the cause of 
psychoses, there are many women who ascribe them 
frankly to a legitimate fear that from brooding came to 
take morbid forms. 

One woman, an enthusiast for Twilight Sleep on this 
very psychological ground, tells how her fear of the ordeal 
gradually developed into a fear of death, until each night 
she dreamed of herself laid out in her coffin. After the 
birth the brooding fear implanted in her remained. She 
was a subject of both pregnancy and puerperal psychosis 



THE PSYCHOLOGY OF MATERNITY 39 

which she will always lay without a moment's hesitation 
to her real legitimate fear of childbirth. 

This woman also is one of those who lay great stress 
on the effect of the mother's state of mind on the unborn 
child. To this day she watches her grown son and fancies 
she detects in his temperament under excitement the ab- 
normal nervous symptoms of her pregnancy. 

The girl's foreboding of childbirth is expressed for all 
time in the Roman poet Catullus' Marriage Hymn, where 
the girls fight the eager boys before the altar of Hymen, in 
a war of words that ends in their magnificent defeat. 

This is one class of women. Many healthy young 
women of good courage approach childbirth as a great ad- 
venture. Others forget its pain in the desire of maternity. 
Some of these retain their courage through successive 
births, though few of them have painless births. Many 
mothers forget ; for there is a slow-working deceptive form 
of natural amnesia which often follows a birth, but does 
not serve at all to obliterate its physical shock. The pic- 
ture of the birth is displaced in their minds by the picture 
of the child. 

One of us personally lived through a sister's confine- 
ment. It was over twenty hours of hard labour followed 
by two months' convalescence — a breakdown solely due to 
an injury to the nervous system. ~Not very long after the 
recovery, the mother was heard to say : "Really, it was not 
so bad!" And presently when she was to have another 
she had forgotten the pain entirely. 

But comparatively few mothers forget. It is the fore- 
boding, experienced mothers, many of whom approached 



40 AUTHENTIC TWILIGHT SLEEP 

the first birth with good courage, who give a tragic reality 
to the fear and pain of childbirth. 

We saw many of these who came to Freiburg. One 
woman would not believe that painless birth was possible. 
"I am not afraid of death, you understand ; but I cannot 
go through that again/' she said breathlessly, beseechingly, 
to the head nurse. "If it grows too bad I trust you, I 
count on you, to put me out of my pain. I want to die." 

We saw at Freiburg also the gratitude of one husband 
when painless childbirth freed his wife of the brooding 
dread that had hung over her since her first child was born. 

Frau von Stein, Goethe's friend, was the mother of 
many. She herself speaks in her memoirs of the unhappi- 
ness brought into her life by the constant apprehension of 
childbirth. 

"There is no real ill in life," said Mme. de Sevigne, 
who had borne children, "except severe bodily pain. It 
racks both body and soul." 

It is not for nothing that the word hysteria comes from 
the Greek word for womb. It is this racking of the soul, 
this distortion of the mind by the nerves which causes 
imaginary symptoms of uterine diseases. 

It is from these cases that that army of suffering women 
come to whom Dr. Kronig's assistant, Gauss, refers, who 
"although they exhibit no signs of definite disease of the 
organs of generation, yet consult the gynecologist because 
they attribute the general nervous complaints caused by 
the memories of child-bearing to these organs." He be- 
lieves it very likely that a nervously high-strung woman 
might often be spared the undesirable illnesses following 



THE PSYCHOLOGY OF MATERNITY 41 

childbirth merely by blotting out her memory of the birth 
itself, in the Dammerschlaf. 

But the soul is not only racked nervously; the very 
quality of the mind itself is sometimes affected by child- 
birth. 

Not a few women of good normal minds have gone to 
seed, become dumb, patient, brooding animals after the 
exhaustion of a succession of painful births. Of these we 
say: "It is a pity she has fallen off so mentally! She 
promised so well when she was a girl." Her own life has 
been shut off from her by life-giving. 

Only when the function of maternity is made less ex- 
hausting by the painless births of the future shall we know 
to the full extent how much this accounts for the irritabil- 
ity, superficiality, and instability alleged against women. 
We may find that it has been a potent factor in retarding 
their development to a position of equality with men. 

For women have always been handicapped by child- 
bearing. It is the great literary "exemplum" of pain. 
"Fear came upon them," says the psalm, "and pain like to 
the sorrow of a woman in travail." 

Until they saw relief in sight, women have borne their 
fear and sorrow with a good grit. Amongst those most 
eager for Twilight Sleep are mothers who want to save 
their married daughters from what they endured. One 
woman wrote us from a Denver hospital where she had 
just had her child with pain, telling of a Twilight Sleep 
hospital in California that she could never hope to get to 
herself. 

Women of all classes, from the sensitive woman of the 
upper class to the neurasthenic and anaemic factory girl, 



42 AUTHENTIC TWILIGHT SLEEP 

have faced the pains of childbirth as a normal incident of 
their lives. 

Except in war or the dangerous trades, men have no 
such ever-present element of danger in their normal lives. 
Medea says, in the Greek play, in the days when war was 
the customary occupation of men : 

And then, forsooth, 'tis they that face the call 
Of war, while we sit sheltered, hid from all 
Peril! — False mocking! Sooner would I stand 
Three times to face their battles, shield in hand, 
Than bear one child. 

There is something particularly eloquent about that 
"shield in hand" ; for it is the helplessness of the woman 
to defend herself that is one of the horrors of childbirth. 

The amnesia of the Twilight Sleep shields her, as we 
have shown by medical testimony, to some extent from its 
perils. 

Painful childbirth was the worst punishment God could 
devise for woman. Adam's part in the curse of Genesis 
has been partly lifted by anesthesia ; Eve's remains. 

The birth rate of all countries equals, of most surpasses, 
the death rate. 

The sum of suffering through birth borne by one sex 
surpasses the sum of suffering by death shared by both. 
To the ordinary diseases to which both sexes are liable 
are added the diseases developing out of childbirth, so 
that women's share in the pain of the world is a heavy 
one. 

All the suffering from normal birth can be done away 
with, and with it no small part of uterine disease. Most 



THE PSYCHOLOGY OF MATEKNITY 43 

women are willing to accept this alleviation, believing with 
Montesquieu that: "The alleviating of pain is a certain 
symptom of the development of that liberty dear to the 
people." 

In opposition to Montesquieu there arises a latter-day 
prophet in the person of the male editor of Harper s 
Weekly: 

"It is a great thing, no doubt, this promised doing away 
with pain ; but as a tonic what shall take its place % How 
much the necessary heroism of all women must have done 
to keep nobility in the race !" 

This proposal to vicariously perpetuate ennobling pain 
would be ridiculous, if it were not that a certain small 
number of stoical women echo his feeling. 

Are they women of the last generation; have they fin- 
ished bearing, and forgotten its pain ? 

Or is this spirit left over from the self-mutilation of 
the savage who needed it to accustom him to the enforced 
sufferings of a savage life ? 

In a way, women's motherhood lagging behind with ob- 
stetrics, the most traditional of the medical sciences, has 
had some elements of the brutal physical experiences of 
the savage. 

But the day of that is over, with the coming of the Twi- 
light Sleep. 

It is most likely that the stoical woman inherits a me- 
diaeval and not a savage sentiment. To most of us the 
stoicism of St. Simeon Stylites seems a form of egotism, a 
concern with his own personal soul at the expense of the 
community. 

Most women to-day will believe that by the wearing out 



44 AUTHENTIC TWILIGHT SLEEP 

of their bodies to preserve their high personal courage 
they sacrifice some of their usefulness to the community. 
Nearer home they sacrifice their child. 

A mother waking from Twilight Sleep was asked by 
her physician whether she did not lose a joy in missing 
the first cry of the child. 

"Lose a joy !" she cried. "This is the only one of my 
children that I have been in any condition to enjoy when 
he first came into the world." 

This was the first of her children that she had been 
able to nurse and the first that she had been well enough to 
take care of herself. 

These are some of the things that motherhood under 
painless birth means to the child. 

"I should think/' said one woman thoughtfully, after 
hearing a talk on Twilight Sleep, "I should think that the 
mother's peace of mind while she was carrying him could 
not help having a wonderful effect on the baby." The 
providing of peace of mind is an essential element of pre- 
natal care, both for mother and child. 

The American woman of to-day believes that the weari- 
ness, the physiological depression, the disturbance of func- 
tion, the giving out of nourishment and energy, the loss 
of good looks, the withdrawal from the customary resources 
of social life in pregnancy is enough of a sacrifice to the 
future. 

She does not believe that it is any longer necessary for 
that year of her life to culminate in a brutal struggle 
and a domestic shambles, she believes that it should cul- 
minate in a rite to motherhood. 

Scopolamin that has come down through the ages is first 



THE PSYCHOLOGY OF MATERNITY 45 

reported in the religious ecstasies of the Greek gods. The 
priestesses of Demeter, the Earth Mother, performed their 
rites under its intoxication. But every mother, from those 
of primitive peoples who have tried to procure this pain- 
ohliterating ecstasy through philtres, incantations, char- 
coal fumes or alcohol, up to the mother drifting cloudily 
under the Dammerschlaf, becomes a priestess of Demeter, 
lifted out of herself into the sublime primal function of 
her Mother Earth. 



CHAPTEK IV 

Gauss and Dammerschxaf : 80% Perfect 

When it became clearly impossible to obtain Dr. Gauss's 
reports by the simple expedient of applying for them at 
the Frauenklinik, recourse was had to the second-hand 
medical book-shelves of the Freiburg bookshops. A faded, 
dust-stained, dog-eared copy of Gauss's 1906 report was 
our ultimate reward. 

Day by day, as this report unfolded itself to us through 
the translation of the English instructor, and we took it 
down, there grew from it the personality of the man who 
had worked out the Dammerschlaf method. 

We, as patients and relatives of patients, ourselves 
knew Gauss as he flashed in and out of our room at the 
Klinik ; as we passed him rushing across the garden with 
his arms full of classroom papers ; as his automobile tore 
past ours on the way to the aviation field where he was to 
make an ascension, for he was attached to the aviation 
corps. One of his colleagues said drolly, with a glance 
at the hall clock in the private ward : "At this hour you'll 
find Dr. Gauss in the ether of the operating room, or the 
ether of the upper air." 

We looked upon him as the enthusiastic social factor of 
the medical faculty, as to whom there was always some 
new stirring anecdote; he would reappear from Berlin, 

46 



GAUSS AND DAMMEKSCHLAF 47, 

where he had been sent to deliver an address, with a per- 
fectly new dance step, or from Switzerland, where he had 
been sent to rest, with all the physical testimonies of a 
fall from a glacier. 

Lequeu, one of the early French students of scopolamin- 
morphin, refers to Gauss as though he were the mechanical 
medium through which Kronig carried out his revolu- 
tionary ideas. 

Lequeu presents Gauss as a drudge, doing automatic- 
ally the routine work of his position. 

The Gauss whom we grew to know through our patient, 
plodding study of the 1906 report was neither a butterfly 
nor a drudge. He was no perfunctory candidate for a 
professorship, accumulating facts under set classifications 
whose meaning was left to others to analyse. There are 
many men of this kind in all universities, and their work 
is dry and useless except to the man who knows what they 
are to prove beforehand. Gauss had a dozen of these 
working for him, recording all the delicate details of the 
great experiment he was making: blood loss, duration of 
birth, pain curves, objective signs of the state of conscious- 
ness, infant's heart and breathing. These worked mechan- 
ically, leaving understanding of their results to him. 

Gauss was never told what to find: but simply to find 
what was best for the mother and child. It was his dis- 
covery that in Dammerschlaf, the technique by which is 
induced and maintained a state of instantaneous forgetful- 
ness never before recognised as anything but an accidental 
passing phase in the progress from consciousness to uncon- 
sciousness, there were possibilities which might be de- 
veloped into an ideal method of painless birth. 



48 AUTHENTIC TWILIGHT SLEEP 

From the great report in which, in 1906, he gave the 
results of his work, it is evident that Gauss approached his 
investigations with as keen an imagination, and as sensi- 
tive an understanding of pain, as Kronig. He never loses 
that imagination throughout the infinite dry plodding 
which his task necessitates. For him details are illumined 
by his underlying purposes. 

And so, just as some diseases and therapeutic methods 
are named for the doctors who first recognised them, the 
artificial Dammerschlaf state of clouded consciousness 
should be associated with the name of Gauss. It was he, 
and he alone, who saw it as the ideal state for the birth 
process, and he, and he alone, who worked out with infinite 
delicacy the method by which it should be induced and 
maintained. 

All through history the narcotic qualities of the atro- 
pin-hyoscin-scopolamin family had been recognised ; sibyls 
and witches have used them in their rites. 

But they had taken a place among surgical narcotics 
generally in combination with morphin as scopomorphin 
for only a few years when, in 1903, the obstetrician von 
Steinbuchel, of Gratz, used a minute hypodermic injection 
of scopolamin combined with morphin, instead of the cus- 
tomary simple morphin, to give short intervals of sleep be- 
tween the pains of a hard labour. He found to his amaze- 
ment that the mother was not awakened by the pains, 
which kept on right through her sleep. Morphin alone in 
sufficient dosage to have kept her sleeping might have 
killed her, but the minute quantity of scopolamin added 
roused the small dose of morphin to greater efficiency, 
lessened its poisonous qualities, and added its own narcotic 



GAUSS AND DAMMEKSCHLAF 49 

qualities, producing a result far beyond his expectations. 

The news of von Steinbuchel's use of scopomorphin ran 
through the world of obstetrics. Kronig was one of those 
who took it up and used it most cautiously and effectively. 
But results were not uniform. Keeping always to their 
minute dosage von Steinbiichel and Kronig had many 
cases which had no pain relief, or incomplete relief. 
Kronig, fully determined on painless childbirth, felt that 
these were only crude beginnings, but that on this basis a 
more perfect method could be worked out. 

In Gauss he had a man with the genius both for taking 
infinite pains in working out details and for grasping a 
great idea. 

Physicians constantly speak of "beautiful" or typical 
cases of some horrible pathological condition or another. 
It must have been beautiful indeed to Gauss to see the 
typical or perfect Dammerschlaf childbirth with the path- 
ological pain element removed. It came gradually to be 
exemplified by mother after mother, a Dammerschlaf per- 
fect in respect to painlessness, to normal birth process, to 
safety of the baby, and in respect to state of conscious- 
ness such that it could regulate and maintain itself. 

Until he was reasonably secure about safety Gauss did 
not deviate much from von Steinbiichers dosage. 

His first experimental mothers were dogs. Very few 
laymen like to think that science learns to study the physi- 
ological phenomena of the human body at the expense of 
pain inflicted on animals. In this case, however, experi-. 
mentation took quite the opposite form of putting partial 
anaesthesia at the service of the "lower" animals. The 
little animals "people" brought to the clinic to have their 



50 AUTHENTIC TWILIGHT SLEEP 

babies were treated in the light of patients. One day a 
new nurse, very tired indeed and nervous from a first day's 
bewildering demands, found that Dr. Gauss expected her 
to assist at the birth of puppies whose mother was enjoying 
scopolamin-morphin. It was too much. Oblivious of dis- 
cipline and etiquette, she fled to the head nurse in a storm 
of tears and protest. The head nurse, remembering per- 
haps her own first days of training, excused her, and al- 
though it fell rather to one side of her own activities took 
the girl's place. 

Geburten in Kiinstliche Dammerschlaf (Archiv fur 
Gynsecologie, Band 78, Heft 3, 1906)— Gauss, 1906— 
is his study of his first 500 human mothers under the 
experiment. It is not only an authoritative document, 
but it has a picturesque simplicity of style and an element 
of romance because of its intense human interest. 

This report, together with the report on a thousand cases 
published the next year, and a third in 1911, constitute 
one of the most careful studies in medical literature of an 
experience carried on under uniform conditions in one 
place. 

Nothing on such a scale had been done before. With a 
supplemental report on several hundred cases the studies 
cover 3,600 of the 5,000 mothers delivered under Dammer- 
schlaf at Freiburg up to the present time. There is an 
unpublished report on 500 more, but this has been seen 
only by physicians. 

Their numbers are so large as to remove the Ereiburg 
Dammerschlaf from the experimental class and show it a 
proved experience which can, as Gauss says in one place, 



GAUSS AND DAMMEKSCHLAF 51 

"serve as a touchstone for all other obstetrical use of 
scopolamin-morphin." 

Gauss, 1906, covers the cases by the study of which he 
came to recognise the value of the state of amnesia or 
instantaneous forgetfulness, and worked out the technique 
by which it could be maintained. We shall leave Gauss 
himself to describe the condition and the working out of 
his technique. 

In his next series of cases he perfected the proportions 
of the two drugs, reducing morphin to the minimum, and 
more perfectly adapted the dosage to the individual tem- 
perament. 

Gauss, 1906, contains the idea roughly blocked out; 
later studies show it in finished perfection. 

Dr. Gauss's description of the stages by which he 
learned to recognise and perfect Dammerschlaf also in- 
cludes the description of two stages of partial Dammer- 
schlaf which are represented in the statistics of the later 
studies. They were included in 1906 under the general 
head of pain-lessening. 

"The first sign of the action of the drug/' says he, "is 
pronounced weariness which very soon passes into a peace- 
ful sleep occupying the whole of the pauses between the 
pains, but out of which the patients are startled by every 
pain. 

"The suffering during the pains is indeed at this stage 
clearly perceived as such, but is considerably reduced in 
fact, and — at least in the case of critical and intelligent 
people — also subjectively. At this stage I have often 
heard such spontaneous remarks as : 'How nice it is to be 
conscious of the pains, but to feel no suffering.' 



52 AUTHENTIC TWILIGHT SLEEP 

"Gradually further signs of the commencing action of 
the drug occur: thirst, with a dry feeling in the mouth 
and throat, flushing of the face, occasionally slight twitch- 
ing in the flexor muscles of the fingers, and sometimes a 
certain degree of motor restlessness. After longer action 
and sufficient dose, the sleep becomes deeper, so that even 
during the pains the patients do not become fully awake, 
and the only signs of the pains are contortion of the 
expression muscles of the face; slight groaning. 

"Consciousness is at this stage fully retained. The 
patient can remember exactly anything done to her. It is 
this stage that those who have hitherto championed the 
scopolamin-morphium semi-narcosis regard as the goal to 
be aimed at. 

"But in consequence of the results of my cautiously 
made investigations, I have gone further. 

"Only a slight deepening of the semi-narcosis is suf- 
ficient so to cloud the consciousness without entirely abol- 
ishing it, that the final result of a skilfully graduated 
dose is a kind of artificial fuddled condition, the principal 
characteristic of which is a complete amnesia extending 
over the whole process of birth. 

"I said to myself, it is undoubtedly a great advance to 
be able to diminish the suffering of the mother. But in 
spite of this, every patient would have the impression in 
consequence of the continuous increase in the intensity of 
the pains up to the end of the birth, that her sufferings, 
in spite of the injection, also increased. Thus, a great 
advantage to the patient would often be greatly under- 
estimated by her, especially in the case of inexperienced 
mothers at the birth of the first child. 



GAUSS AND DAMMEKSCHLAF 53 

"As, however, a slight increase in the dose injected is 
sufficient to produce total loss of memory of the sufferings 
during birth, and of all the occurrences taking place while 
the dose remains effective, there seemed to me to be no 
doubt that the object of the 'semi-narcosis' must be to put 
the patient into that kind of clouded consciousness which 
she afterward is unable to remember. 

"It is this point which distinguishes my investigations 
and results, in principle, from those of other obstetricians, 
who were all satisfied with having reached only painless- 
ness, or, to speak more accurately, a sort of sub-pain- 
lessness. 

"The patients react in very varying manner whilst in 
this condition of clouded consciousness (Dammerzustand) . 

"The majority of the patients impress one as being 
indeed sleepy, but otherwise quite normal. Every pain 
is accompanied by clearly perceptible if often only slight 
expressions of suffering. The pains and the accompanying 
sufferings are referred to and felt clearly as such. Every 
question is perhaps sleepily but nevertheless clearly 
answered. 

"In this stage nothing beyond the very pronounced 
weariness of the patient strikes the unprejudiced layman 
or even a medical man who was unaware that an injection 
had been given. So much the more astonishing is it sub- 
sequently to learn that the patient whom one believed to 
be completely conscious has, after the birth, not the slight- 
est idea of what she has just been through, or of the 
conversation held with her. 

"The term semi-narcosis does not do justice to the pecu- 
liarity of this most curious condition of consciousness, 



54 AUTHENTIC TWILIGHT SLEEP 

which has much more resemblance to the waking condition 
than to narcotic trance. 

"The patient is in a stage of artificial sleep from which 
she may wake or be awakened at any moment for a short 
time. At the same time, however, during the whole period 
of the action of the injections she displays the amnesia 
characteristic of this clouded mental condition. 

"Taking into consideration these two principal symp- 
toms of this intentionally produced and peculiar condition, 
and also the difference in principle between it and the 
conditions of semi-narcosis hitherto reported on, I consider 
myself entitled to speak of my method as an artificial 
Dammerschlaf. 

"If it is perhaps intelligible that the patient should no 
longer clearly remember events further in the past, it is 
yet sometimes in the highest degree striking how little 
remains in the memory during the reign of this artificial 
state of clouded intelligence of the most important occur- 
rences in the immediate past, for example, the birth which 
has just taken place. It may perhaps be of interest if I 
here give a few examples of daily experiences in our 
delivery ward." 

Gauss continues, describing how the instantaneous for- 
getfulness appears to the mother : "I have often seen the 
patient, after the last and successful ejection pain, sink 
back on the pillows with the sigh of relief (' Thank God, 
that's all over!') She had consequently, at the moment, 
a clear preception of the birth that had taken place, and 
took also the greatest interest in the child, its sex, state of 
health and crying. If, however, she were asked about ten 
or twenty minutes later some such question as when her 



GAUSS AND DAMMEESCHLAF 55 

child was coming, she would reply that she didn't know ; 
that it wouldn't be much longer, or would give some 
similar answer which clearly showed that the fact of the 
birth having taken place, although it had been certainly 
perceived, had yet not been included in the storehouse of 
memory. In others words that — as the alienists say — it 
had been perceived but not apperceived. 

"At this stage it is my custom to show the mother her 
child. At this dramatically effective moment the mothers 
divide themselves into two groups. 

"Those of the one group, obviously those sceptically 
inclined, will not hear of the suggestion that they have 
borne a child without pain, and are either offended or 
amused. Some of them declare the child to be ugly and, 
therefore, probably the property of the occupant of the 
next bed. 

"The others, in consequence of our having previously 
discussed painless birth with them, are more predisposed 
to belief although with the utmost astonishment they 
rejoice that they have already got through the birth. It is, 
however, quite easy subsequently to suggest to them that a 
joke has been played on them, if indeed they have not 
already after a quarter of an hour entirely forgotten that 
the child had been shown them. 

"A patient of this type presented her own child to her 
indignant and horrified husband as being that of her 
neighbour, at the same time expressing the greatest longing 
that the child she was expecting should also be a boy. 

"I felt able in this case to promise the woman a boy 
with the greatest confidence." 

"The Dammerschlaf," says Gauss in his 1911 report, 



56 AUTHENTIC TWILIGHT SLEEP 

"is a narcotic condition of extremely limited breadth, like 
a narrow mountain crest. To the left of it lie the dangers 
of too deep effect, with unconsciousness and absence of 
birth pains; to the right the danger of too shallow effect, 
with retention of consciousness and sensibility to pain. 

"What we term consciousness is the sum of the simul- 
taneous mental processes into which internal and external 
stimuli are transformed. Derangements of the conscious- 
ness are consequently pathological deviations from the 
regular course of these mental processes, which can exhibit 
various degrees of clearness according to the magnitude of 
the liminal value. A clouding of the consciousness in 
which the clearness of consciousness falls below a certain 
standard, we term 'Dammerzustand.' 

"Owing to the fact that the associative bridges between 
the consciousness during the term of this condition which 
we have just defined, and that of the waking condition, 
are for the most part broken down, there is a more or less 
well marked defectiveness of memory for events occurring 
during the befoggled condition; the same kind of defect 
which we also observe in the amnesia occurring after 
scopolamin-morphium injection. 

"Amnesia in general is a derangement of the memory 
which may take either of two completely different forms. 

"For we distinguish between weakness of memory, 
which consists in a diminution or loss of the capacity for 
remembering past impressions, and the derangement of 
perception which is characterised by limitation of the 
formation of new memory pictures and images. In the 
amnesia produced by scopolamin-morphium the retention 



GAUSS AKD DAMMEKSCHLAF 57 

of already formed memory pictures and concepts is not 
affected, but only the formation of new ones. 

"It must consequently be also conversely possible by 
testing the capacity of perception to arrive at conclusions 
as to the subsequently appearing amnesia and so as to the 
intensity of the action of the scopolamin-morphium at the 
moment. 

"My at first not very sanguine expectations were con- 
firmed by the favourable results of the experiments. The 
so-called scopolamin visit always paid to the patients 
after they had fully returned to consciousness in order to 
ascertain the final effect led regularly to the result that 
amnesia also set in as soon as the derangement in apper- 
ception began. 

"Since that time I have guided myself as to dosing 
almost altogether according to the variations of the care- 
fully tested capacity of apperception, and have, when these 
tests have been properly carried out, never been misled 
as to the state of matters at the moment. 

"In the rare cases in which the carrying out of this 
presented difficulties on account of the dementia of the 
patient, or for other reasons, I observed the reaction to 
pain of the pupils, and the locomotor ataxia and utilised 
them as very welcome and valuable auxiliaries. 

"The value of these auxiliaries is further increased by 
a certain regularity which a systematic observation of 
their order in time would seem to show. 

"The power of apperception is the most delicate indi- 
cator for the beginning of the action of the drug. Then 
come in order of sensitiveness, the locomotor co-ordination 
and the pupillary reaction. The maximum action was 



58 AUTHENTIC TWILIGHT SLEEP 

consequently reached when the pupillary reaction ceased 
whilst the Dammerschlaf condition had already begun and 
was closely related in time with the cessation of the powers 
of apperception. 

"It is clear that accurate checking of the intensity of 
the action of scopolamin-morphium will not always be so 
very easy. Curiously enough it is most difficult in the 
case of extremely demented and of highly intelligent 
persons. But an effective maintenance of artificial Dam- 
merschlaf is impossible without both a continuous and 
skilled testing of the condition as to consciousness at the 
moment. In cases therefore where it is impracticable for 
the medical man or — as is now done in the Freiburg 
clinic — for a skilful and well trained, experienced obstetric 
nurse to keep a close observation on the whole course of 
the birth, nothing but repeated failures are to be looked 
for in the general results. 

"I had myself enough and to spare of such failures 
until I had learned to carefully eliminate every factor 
which was interfering with the action of the injections. 

"The first necessity in my opinion is that the patient 
should as far as possible be shielded from all powerful 
stimulation whether mental or physical. It is conse- 
quently best to have the patient in a room by herself, 
where nothing disturbs the quiet beyond the proceedings 
necessary for the birth. Loud conversation, penetrating 
noises, the coming and going of relatives, in short every- 
thing that sets the patient's senses to work is carefully 
avoided. 

"How greatly just these stimulations which act upon 
the sense organs can interfere is shown by the observation 



GAUSS AND DAMMERSCHLAF 59 

we have often made that patients have apperceived nothing 
of the birth except the crying of the newly born infant, 
and that it is from this alone that they infer that the birth 
has taken place. We have, therefore, made it a custom 
to convey the child as soon as possible out of hearing of 
the mother, and if necessary to smother its cries still 
sooner by laying a cloth over it. More recently we have 
reduced stimulation of the sense of hearing with con- 
siderable success by the use of antiphones, or balls of 
cotton wool dipped in oil and put into the ears. 

"The sudden turning on of the electric arc lamps in 
our obstetric operating room has often just as great a 
disturbing effect. The sudden stimulation of the eye 
impresses itself only too easily on a patient lying in 
Dammerschlaf as a persisting memory, and is often the 
cause of inopportune awakening. Protection of the eyes 
from such stimulation or, if necessary, a reduction of it by 
dark coloured cloth or coloured spectacles facilitates the 
maintenance of an uninterrupted artificial Dammerschlaf. 

a The muscular sensation and the sense of balance have 
often made permanent impressions which as regards time 
lay in the sphere of the Dammerschlaf. The feeling of 
being lifted, of the transportation, has often remained as 
an isolated recollection. Several women can also remem- 
ber a feeling that they 'had suddenly become so empty,' 
or that something had suddenly come out of them. They 
do not generally arrive at the conclusion that this sensa- 
tion was due to the birth of the child or of the placenta 
until afterward, if at all. At the time when we made 
extensive use of the application of the hanging position 
a series of patients could clearly remember that they had 



60 AUTHENTIC TWILIGHT SLEEP 

lain in a position in which the head had been downward 
and in which they had the feeling all the time of slipping 
down an inclined plane. 

"The organs of touch and of perception of pain showed 
themselves, as indeed lay in the nature of the case, least 
sensitive to stimulus. Bodily pain was with relative dif- 
ficulty apperceived by women in Dammerschlaf. The first 
of the pains due to the birthpangs to disappear from the 
consciousness are the feelings due to the contractions of the 
uterus, whilst those due to compression and dilatation of 
the soft parts are perceived for some time afterward. " 

But the memory test whether applied directly or indi- 
rectly is the essential ; by this the method stands or falls. 

"The power of the memory is, and remains/' says 
Gauss, "the only guide. If we consult the memory, and 
test it in strict accordance with the rules laid down, then 
the Twilight Sleep is devoid of danger, as is shown by 
our statistics, and is a great boon, as is proved by the 
gratitude of our patients." 

ISTot a set interval of time but relevant response to the 
memory tests shows that a new dose is needed. So too 
no set doses are given but the minimum dose that will put 
the individual patient into a state of amnesia. The initial 
dose, which is given to women having their first child when 
pains are irve minutes apart, to mothers of many at the 
beginning of labour, ranges from 1/150 to 1/130 of a 
grain of scopolamin, seldom more. With the first dose 
alone one-quarter of a grain of morphin is used. Succeed- 
ing doses of scopolamin are much smaller than the first. 
So wide is the range of sensitiveness, as shown by the 



GAUSS AND DAMMEKSCHLAF 61 

memory test, that the periods between doses vary by as 
much as from one and a half to four hours. 

To prevent the sleep from being broken into by appeals 
to the senses Gauss provided as far as possible seclusion 
for each patient behind padded doors and under the dim 
light of a twilight lamp. How important this seclusion 
is is shown by the fact that in the free wards where con- 
ditions are not ideal almost three times as many patients 
have an unsuccessful sleep. 

With his first fiye hundred cases Gauss had sixty-five 
per cent, of complete painlessness and about thirteen per 
cent, of patients who for one reason or another could not 
be brought under the influence of the narcotic. Disturbed 
environment, temperamental refractoriness, and a first in- 
jection too near the end of birth were the causes. The 
cases in between ranged from mere pain-lessening to a 
condition almost as satisfactory to the mother as deep 
Dammerschlaf. 

Pain-lessening and a further condition in which some 
memory exists is described in the account we have quoted 
of the stages by which Gauss led his patients to perfect 
amnesia. 

In the reports published in 1907 and 1911 deep Dam- 
merschlaf shows the same percentage. 

Patients with a few "memory islands" but who never- 
theless are satisfied with their sleep are grouped as partial 
Dammerschlaf. These, with the perfect groups, make 
eighty per cent, of what is from the mother's point of view 
practical painlessness. In the first ward, where the envi- 
ronment is best and the doctors most skilled, ninety-five 
per cent, of patients have painless births. 



62 AUTHENTIC TWILIGHT SLEEP 

In starting his experiments Gauss laid down for him- 
self certain stringent conditions. These were that the 
narcotic must have no injurious effect on the mother, the 
birth process, or the child. 

"Eor the mother, it must be without unpleasant acces- 
sory or after-effects, such as nausea or blood loss, and 
without interference with the birth process, or the after- 
birth contractions. 

"Eor the child, the narcotic must have no injurious 
effects during the birth process, the initial bodily func- 
tions, the first year of life, or the later development." 

To insure this safety he excluded from his first cases 
those which presented certain specified complications. 

"Later on," says he in his report, "in reliance on my 
own favourable experiences of the method, I saw even in 
these complications no contrary indication, but gave injec- 
tions to practically all mothers who gave their consent." 

Mothers with weak birth-pains were stimulated by 
quinin or pituitrin. It was even found possible with the 
help of a preliminary whiff of chlorethyl to narcotise some 
mothers who came to the hospital so late in painful and 
rapid labour as not to give the scopolamin-morphin the 
usual time to begin work. In the 1906 report only seventy 
per cent, of the women in the hospital were given scopola- 
min-morphin, later it was offered to one hundred per cent. 
If Gauss did not fear for the delicate women or the com- 
plicated cases, neither did he see why Dammerschlaf 
should be withheld from the normal ones. 

"An opponent of scopolamin-seminarcosis," said Gauss 
in an address in America, "once said that he considered 
the method to be justifiable only in the case of those 



"Sonny Boy," an excellent specimen of a Dammerschlaf baby. His 
father, an assistant professor of the Freiburg University, uses scopol- 
amin in preference to atropin in ophthalmological practice. 




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GAUSS AND DAMMEBSCHLAF 63 

women who, by reason of the state of the general health 
and in particular that of the nerves, are not capable of 
standing the strain of child-bearing if f ully conscious. If 
he thinks it permissible to grant the relief afforded by 
seminarcosis to an organism that is not completely normal, 
then I really cannot understand why this advantage should 
be withheld from strong and healthy mothers; and as a 
matter of fact, it is our principle in Freiburg to give 
every woman who does not object to it the advantages of 
seminarcosis during labour, and we have never had any 
reason or occasion to depart from this principle." 

Gauss dwells in his 1906 report on painlessness as an 
aid to birth: 

"The fact that there is absolutely no memory of the 
exertions which towards the end of the birth become more 
and more frequent and intense, does away with that con- 
dition of mental exhaustion that we so frequently observe 
in protracted births. By this I mean a condition in which 
birth-pains occur, but the patient in consequence of her 
mental and physical exhaustion is not in a condition to 
take effective advantage of them by active co-operation. 

"It is obvious that sensitive and nervous individuals 
are most liable to this undesirable interference with the 
progress of birth which is so often observed and is known 
as secondary insufficiency of birth-pains. 

"It is precisely in the case of patients who are already 
in a highly excited condition when they come to be treated, 
and especially in the case of those who have previously 
had to endure fruitless attempts to deliver them, that the 
effect of the injections is so beneficial that under such 



64 AUTHENTIC TWILIGHT SLEEP 

circumstances I should be sorry to have to do without 
them. 

"I believe I am entitled to ascribe yet another quite 
special advantage to the amnesia obtained by means of 
scopolamin-morphium Dammerschlaf. It is well known 
how seriously the nervous system of a woman is or may 
be affected by a difficult birth which demands the exertion 
of the last remnant of her mental and bodily strength, 
and that such a birth, if a corresponding tendency already 
exists, might possibly give rise to more or less severe 
nervous exhaustion in which the memory of the terrors 
of childbearing, and the fear of a repetition of them may 
reduce the woman's capacity for work and embitter her 
whole life. The army of suffering women who, although 
they exhibit no signs of definite disease of the organs of 
generation, yet consult the gynecologist because they 
attribute the general nervous complaints caused by the 
memories of childbearing to this region, shows emphatic- 
ally how extremely injurious to the nervous system a birth 
may be in an organism disposed to nervous weakness. 

"Now there can be no possible doubt that birth loses the 
character of an injurious trauma to the same extent as 
the physical suffering and the mentally injurious impres- 
sions are reduced or even completely abolished. 

"It is, therefore, not only easily conceivable but even 
very likely that a woman with a predisposition to nervous 
troubles — nervous attacks caused by overexertion, neuras- 
thenia, hysteria, etc. — might be spared the undesirable 
sequelae of childbirth to which she might otherwise easily 
have fallen a victim, merely by blotting out her recollection 
of it. 



GAUSS AND DAMMEESCHLAT 65 

"Although considerations of this kind are of the nature 
of theories, which it is difficult to rigidly prove, yet one is 
certainly to some extent justified in drawing conclusions 
from the degree of exhaustion exhibited by the patient on 
leaving the delivery room as to how far she has been tried 
by the birth. How many women feel the effects for days, 
and cannot get rid of the exhaustion and lassitude which 
remain. It is perhaps due to the avoidance of this state 
of exhaustion that the women delivered under the influence 
of scopolamin-morphium almost always pass the very first 
night after the birth in a deep and refreshing sleep which 
many a woman delivered in the ordinary manner cannot 
obtain although greatly in need of it. 

"The statement so often made to me that a patient had 
never been so comfortable after a birth, the repeatedly 
made observation that the women in consequence of their 
loss of memory believed that they had been in labour for 
only about a third of the real time — these two facts can 
only confirm me in the belief that in the scopolamin-mor- 
phium Dammerschlaf we have an efficacious means of 
doing away with the nervous sequelae of childbirth." 

The voluntary extension of the blessings of painlessness 
to so many more patients than at first enjoyed them is an 
indication that Gauss was satisfied that scopolamin-mor- 
phin in Dammerschlaf was safe. 

His study of all details of these births, each of which 
was taken up by an assistant shows : 

"(1) That duration of birth is normal as compared 
with the averages collected from the statistics of a dozen 
obstetricians of universal reputation. 

"(2) That the birth 'pains/ or muscular contractions, 



66 AUTHENTIC TWILIGHT SLEEP 

which can be observed by the sensitive hand of the doctor, 
and measured, and recorded on the chart by curves, are 
not impaired. 

"(3) That blood loss is no more than the physiological 
loss incidental to all normal births. 

"(4) That there is no injury to the child during or 
after birth." 

The duration of the Dammerschlaf birth was not longer 
than the average recognised by all obstetricians. How 
much this means in the shortening of those births which 
would in consciousness be impeded by secondary insuf- 
ficiency due to inhibitory pain is brought out by the fact 
that some births were as a matter of fact slowed down by 
the narcotic to the extent of from one-half to one hour 
and others which, like cases of small pelvis, needed the 
waiting method to overcome structural difficulties were 
allowed to take their full time without operative inter- 
ference. 

In the early cases the forceps was used occasionally in 
cases where the birth was slowed. On the other hand the 
forceps as a reliever of pain was entirely cut out. And 
with the second group of Ryq hundred cases the physicians 
felt less nervous about a slight slowing down especially as 
the percentage of slowing was lowered with the perfecting 
of the dose. The use of the forceps had been cut in half in 
the 1907 report. At present it is used in a little over six 
per cent, of all cases, a low average. And this percentage 
includes cases where it is used in demonstration cases for 
teaching purposes. 

No other form of operation, great or small, was necessi- 
tated by Dammerschlaf. 



GAUSS AND DAMMEKSCHLAF 67 

Up to very recently Gauss has been forced, in addition 
to observing the difficult technique, to watch his drug very 
closely, for scopolamin had serious chemical characteristics 
which made it readily deteriorate. He early discarded 
the inferior drug hyoscin and gave infinite pains to 
properly guarding the stability of the scopolamin. Ee- 
cently Professor Straub of the Pharmacological Depart- 
ment of the University of Baden has prepared a stable 
form of scopolamin, and this side of the work of the Dam- 
merschlaf administration is made easier. 

The patient's rapid convalescence, the rapidity with 
which the organs were restored to the normal, and the 
fact that a slightly larger percentage of mothers nursed 
their babies showed the positive advantages of painlessness. 

Through this saving of energy, which could be given 
out in nourishment, the child gained also, as he did 
through the cutting down of the use of the forceps. 

Of the effects upon the child, Prof. Gauss says : 

"As the possibility of the vital functions of the new- 
born child being influenced by the narcotic cannot be dis- 
missed a priori, I did not in my first cases make use of the 
injection unless I was already in a position to end the 
birth at once at any moment; that is, in general, never 
till toward the end of the initial stage. As no injurious 
effects of the injections on the child before delivery could 
be detected by the most careful observation, I soon con- 
siderably increased the duration of the Dammerschlaf. 

a The experience obtained from the births hitherto ob- 
served have absolutely convinced me of the innocuousness 
of Dammerschlaf in regard to children. This confidence- 
is best shown by the rule now invariably followed of be- 



68 AUTHENTIC TWILIGHT SLEEP 

ginning the injections as soon as the pangs occur at regular 
intervals and are found unpleasantly painful by the pa- 
tient, without any regard for the stage which the birth 
may have reached or the complications that may be 
present." 

Of five hundred children born alive, three hundred and 
sixteen were brisk and lively. One hundred and nineteen 
showed a condition of intoxication which presents the 
following appearance, as described in 1906 : 

"The newly born infant takes one deep breath at the 
moment of birth with a more or less loud cry, and then lies 
sometimes motionless and sometimes moving its limbs, the 
heart's action continuing. 

"It is only now and then that a short breath is taken, 
so that between them the appearance of recurring cyanosis 
is presented in consequence of the accumulation of car- 
bonic acid gas and the lack of oxygen in the body. At 
the same time it opens its eyelids but then immediately 
allows them to close again slowly as if tired. The diam- 
eter of the pupils is meanwhile so extremely various that 
no inference can be drawn as to the intensity of the nar- 
cotic action. In the majority of cases the diameter was 
equal to or greater than the average. 

"The following symptoms are also especially character- 
istic of this intoxication-like condition: The children re- 
spond vigorously to stimuli, but the reflex muscular actions 
so occasioned are often quite suddenly interrupted before 
they are complete, as if the carrying-out of the intended 
movement had been all at once forgotten. The action of 
the heart meanwhile is clearly dependent on the nature 
of the breathing. As the interval from the last breath 



GAUSS AND DAMMEKSCHLAF 69 

increases, the infant's pulse slows down gradually to about 
sixty beats, rising immediately again to the normal fre- 
quency as soon as the next breath is taken. This process 
is continually repeated at continually diminishing inter- 
vals until the breathing either spontaneously or in conse- 
quence of external causes, becomes regular. From the 
moment at which regular breathing begins, the children 
no longer show any deviation from the normal. 

"In my earlier cases this condition inspired me with 
great uneasiness, and I consequently considered myself 
bound to immediately commence measures for resusci- 
tation. 

"Gradually, however, by cautiously delaying my inter- 
vention, in suitable cases, I found that this anxiety was 
exaggerated, so that at various times for the sake of experi- 
ment I calmly waited to see whether the child would begin 
to breathe properly without any outside intervention. 
Various infants treated in this way for over fifteen or 
twenty minutes established regular breathing without 
assistance, the breathing action becoming more and more 
frequent, and finally absolutely regular. If the question 
is asked whether children born in this condition of intoxi- 
cation would get over their apnea or oligopnea even with- 
out medical assistance we can answer yes with that degree 
of probability which we in medicine have a right to 
expect." 

A visiting doctor who observed this small group of 
sleepy births under Twilight Sleep for himself writes : 

"This group of children are born rosy and fresh. The 
heart beats somewhat slowly, and the child breathes very 
superficially. Once in a while it opens its eyes. Its ap- 



70 AUTHENTIC TWILIGHT SLEEP 

pearance does not create any anxiety in the spectator, and 
perhaps a minute or two afterward normal breathing 
sets in." 

Asphyxia, which is the most serious breathing difficulty 
at birth, does not occur as a result of scopolamin-mor- 
phin, and the percentage of these rare cases where it has 
occurred, due to various other causes, is the same as it was 
in the Frauenklinik before the introduction of Twilight 
Sleep. 

The ideal birth condition of the infant is described by 
Gauss as brisk and lusty, and though he soon discovered 
that the drowsiness referred to above was entirely with- 
out danger to the child, he set himself to avoiding it by 
reducing to a minimum the amount of morphin used in 
the earlier stages of the mother's sleep, and reducing the 
amount of the combined drug to the least possible propor- 
tions compatible with preserving this sleep. 

In this way, between his report on his first five hundred 
cases and the report on his first one thousand cases, pub- 
lished a year later, he had reduced the percentage of 
drowsiness from twenty-three per cent, to twelve per cent. 
To-day, less than a tenth of the children are born in a 
drowsy condition. 

As the years rounded out, and the figures for infant 
mortality under Twilight Sleep were examined and com- 
pared with the mortality at birth for several years in the 
Grand Duchy of Baden, it was found that the Frauen- 
klinik mortality was a great deal less, some years less 
than half, that of Baden. Thinking the hospital environ- 
ment might have something to do with this, the doctors 
looked back over the Frauenklinik's own mortalitv death- 



GAUSS AND DAMMEBSCHLAF 71 

rate in the tea years before Twilight Sleep was introduced. 
They found that the rate for that ten years, 3.4 per cent, 
of all babies born, was more than twice the rate for the 
six years under Twilight Sleep. And this lessened death- 
rate for infants continues to be a characteristic of births 
under Twilight Sleep. It has cut the infant death-rate 
of the Freiburg Klinik from 3.4 per cent, to 1.3 per cent. 

A partial explanation of this low death-rate was offered 
by Professor Aschoff, of the Department of Morbid Physi- 
ology of Freiburg University. He conjectures oligopnea 
to be the safeguard of the Frauenklinik baby and the pos- 
sible cause of the cut in the infant death-rate. 

"A fraction of infant mortality at birth/' says Pro- 
fessor Aschoff, "has been found to be due to the infant's 
attempts at premature respiration, and consequent inhala- 
tion of amniotic fluids. The autopsies of babies that have 
died in this way have shown the bronchial passages choked 
with these poisonous fluids. Such premature effort at 
respiration, owing to a momentary interruption of the 
placental supply of oxygen, is not made by the scopola- 
min baby, through whose system an infinitesimal trace of 
the mother's drug has passed, to be entirely thrown off (as 
Dr. Holzbach's experiments show) by the child's kidneys 
within a couple of hours after birth." 

Klotz, in a large study of the after lives of children 
born in long and difficult births, did not find that a breath- 
ing impediment due to the birth had any effect on the 
child's after-development. 

Hanner, in his study of defective children in the 
Breslau Klinik, could find no connection between such 
impediments and later mental development. 



Y2 AUTHENTIC TWILIGHT SLEEP 

No ill effects are to be feared for the child from the 
use of Dammerschlaf, and we have quoted the fact that 
the infant mortality at birth or shortly after birth has 
been greatly lessened. Dr. Holzbach showed also that the 
infinitely minute traces of the drug are entirely thrown off 
by the organism within a couple of hours after birth. 

The fact may also be demonstrated that the child may 
be said to derive certain benefits, normally, from a Twi- 
light Sleep birth. Eor one thing, during the first year of 
life less than eleven per cent, of Frauenklinik children 
died in a year when the relative mortality of Baden for 
babies in their first year was sixteen per cent. Is it pos- 
sible, for instance, that a rested, healthy mother can take 
better care of her child's first year? In the matter of 
nursing, two independent inquiries by the Erauenklinik — 
groups of women confined under the same conditions — 
showed that considerably larger proportion of those who 
had been confined with Twilight Sleep were able to nurse 
their children. One of these inquiries showed a small 
percentage in favour of Twilight Sleep mothers ; the other 
showed that sixty-seven per cent, of the mothers who had 
borne their children in full consciousness nursed their 
children, while seventy-seven per cent, of the Twilight 
Sleep mothers were able to nurse their children. 

Over a period of eighteen months, eighty-three per cent, 
of the mothers confined under Twilight Sleep were found 
to be nursing their children. 

This may be a coincidence. These may be two coinci- 
dences : the lower death-rate and the higher percentage of 
nursing mothers ; but they tend to show that the Twilight 
Sleep baby does not have any unusually hard struggle for 



GAUSS A1STD DAMMEESCHLAF IB 

existence as compared with his elder brother whose mother 
bore him in suffering. 

Gauss kept in touch with over four hundred of the 
Twilight Sleep babies that had been born at the Klinik. 
Their mothers, many of them, sent the babies' pictures 
from year to year, so that the Klinik has a valuable collec- 
tion of later data about its early Dammerschlaf babies. 
Some of these are nine-year-old girls and boys who still 
live in Freiburg and their mental and physical develop- 
ment is normal in every way. 

An American obstetrician, Dr. J. O. Polak, whose 
report is quoted elsewhere, makes the statement that Frei- 
burg Frauenklinik has the lowest infant and mother mor- 
tality of any clinic in Europe. 

With the publication of the 1906 report, Gauss's great 
pioneering work was done. He had found in the state of 
clouded consciousness, which he called Dammerschlaf, an 
ideal form of painless birth. He had delimited this condi- 
tion, laid down exact rules for its safe and accurate prac- 
tice. He had laid emphasis on the use of stable solutions 
of scopolamin, on minimising the quantity of morphin, and 
on the individualising of the patient. And again and 
again he had underlined the key to the whole method: 
That testing of the powers of memory which is the only 
guide to individual dosage. 

As Drs. Harrar and McPherson say in a recent Ameri- 
can report: "It is a phenomenon as interesting as the 
Twilight Sleep itself that detailed descriptions of the tech- 
nique have lain idle in the literature for six years with 
no one taking advantage of them." 

In concluding his report, Gauss says simply: 



74 AUTHENTIC TWILIGHT SLEEP 

"I herewith condense the result of my work as follows : 

"The Dammerschlaf produced by scopolamin-morphium 
is able to limit the suffering of the woman in labour to 
the lowest minimum imaginable. 

"This object is attained: 

Without disagreeable secondary effects upon the sub- 
jective condition of the woman in labour. 
Without substantial interference with the labour 

itself. 
Without danger to the mother. 
Without injury to the child. 

"The scopolamin-morphium Dammerschlaf renders pos- 
sible a truly humane execution of the didactic duties of 
the institutes of learning without tormenting interference 
with the woman in labour. 

"The scopolamin-morphium Dammerschlaf during 
birth, therefore, is a method till now unparalleled, and 
proves to be a blessing to the doctor and the patient, to 
the clinical instructor and the disciple." 

Such is the record of the scopolamin-morphin Dammer- 
schlaf as worked out at Freiburg. It has proved itself 
to have no elements of harm to mother or child, and has 
furnished in eighty per cent, of a large number of cases 
complete pain obliteration. 

The Freiburg Dammerschlaf is, as one American pro- 
fessor has expressed it, the eighty per cent, perfect method 
— eighty per cent, perfect as to both pain-obliteration and 
practicability, because it requires special conditions for its 
success. 

This professor expressed his hope that a one hundred 
per cent, method would in time be worked out, one that 



GAUSS AND DAMMEKSCHLAF 75 

would always succeed and one that could be used by all 
doctors in all places. Perhaps such a method is even now 
being worked out somewhere, or perhaps the scopolamin 
Dammerschlaf will set other doctors to working toward it. 
In the meantime, and since popular agitation for it has 
lifted the technique of Twilight Sleep out of the oblivion 
of obstetrical literature in which it lay with no one taking 
advantage of it, it may be instructive to the lay-woman 
to learn how another great obstetrician, Sir James Young 
Simpson, tried in 1847 to give painless childbirth to the 
world, and how his method was killed. 



CHAPTER V 
How Simpson's Method Was Killed 

Painless birth under a condition like Twilight Sleep 
goes back two generations. The first spontaneous birth 
under artificial painlessness was in 1847. Sir James 
Young Simpson's statue is pointed out in Westminster 
Abbey. He is famous as one of the discoverers of anaes- 
thesia. But it is not generally known that in the working 
out of the possibilities of general anaesthesia he took no 
great part. His sole and 'persistent original work was with 
obstetrical semi-anaesthesia^ or the attaining of painless 
spontaneous birth, and the demonstration of its humane 
and scientific value. 

When in 1847 he was appointed physician to Queen 
Victoria, his friends who called that very day to congratu- 
late him, were astonished to find him in a profound ab- 
straction, preoccupied to the exclusion of any thought of 
the honour done him. 

"I am far less interested," he explained to them, "than 
in having this day delivered a woman without pain while 
inhaling sulphuric ether. I can think of naught else." 

This is the first artificially "painless baby" recorded. 

Over this obstetrical use of ether and chloroform, and 
over this use alone, was waged the sensational religious 
controversy about anaesthesia. Simpson answered his op- 

76 



HOW SIMPSON'S METHOD WAS KILLED 77 

ponents as patiently as though they deserved serious con- 
sideration, returning them biblical quotation for biblical 
quotation. He pointed out, as a high dignitary of the 
church has since himself pointed out, that the same quota- 
tion from Genesis likewise enjoined suffering on Adam. 
Yet medicine was continually occupied to relieve this 
suffering by anaesthetics with the full approval of the 
church. 

He dismissed with contempt the minister of Moloch 
who feared that it would "deprive God of the earnest cries 
that rise to him for succour in time of trouble." 

To us to-day, he seems to have made his point best 
when with fine irony he called the attention of the male 
clergy and medical profession to the fact that in the only 
case of male parturition recorded in history, real or 
legendary, "The Lord God caused a deep sleep to fall on 
Adam and he slept and he took out one of his ribs and 
closed up the flesh instead thereof." 

His scientific opponents too he placed by his wit in a 
position which the absurdity of their arguments warranted. 
They did not even attempt to put their attacks on scien- 
tific grounds. 

"They decried it," says Simpson's nephew, Dr. A. ~R. 
Simpson, of Edinburgh University, "as an unnecessary 
interference with the providentially arranged process of 
labour." Dr. Montgomery, the then chief of the great 
Dublin School of Midwifery, wrote a letter to Edinburgh, 
in which he said : "I do not believe that any one in Dublin 
has as yet used ether in midwifery; the feeling is very 
strong against its use in ordinary cases, and merely to 
avert the ordinary amount of pain which the Almighty has 



78 AUTHENTIC TWILIGHT SLEEP 

seen fit — and most wisely we cannot doubt — to allot to 
natural labour, and in this feeling I heartily and entirely 
concur." Above the words "ether," "midwifery," etc., 
Simpson marked alternative readings. "I do not believe 
that any one in Dublin has as yet used a carriage in loco- 
motion ; the feeling is very strong against its use in ordi- 
nary progression, and merely to avert the ordinary amount 
of fatigue which the Almighty has seen fit — and most 
wisely we cannot doubt — to allot to natural walking, and 
in this feeling I heartily and entirely concur." 

The first living child which Sir James brought into 
the world painlessly was in a case complicated by a pelvis 
so narrow that a first child had been sacrificed by crani- 
otomy. With pain removed Simpson could use the waiting 
method now so much followed in cases of that sort, and 
in the end the mother bore spontaneously a living child. 
She woke saying: "She had enjoyed a very comfortable 
sleep and indeed required it, as she was so tired. But she 
would now be more able for the work that was before her." 
Presently she remarked that she "was afraid the sleep had 
stopped her pains." Like many a Freiburg Dammer- 
schlaf mother to-day, she would not believe it to be her 
own living baby that was handed her. 

In after years this baby's picture, grown-up as she 
appears here, was shown by Simpson's son to a friend, 
who, "as he remarked the mild angelic air that rested 
upon the upturned face above the folded hands, said that 
it might stand for a picture of Anaesthesia, and it was a 
pity that the girl had not been called by that name." 

If Miss Anaesthesia's picture were hanging to-day in the 
National Portrait Gallery possibly more women would 



HOW SIMPSON'S METHOD WAS KILLED 79 

know of the boon of painless childbirth which Simpson in 
1846, like Kronig and Gauss in 1914, aimed to give all 
women. 

Simpson went steadily on in his experimentation, ex- 
pressing more and more satisfaction with obstetric semi- 
anaesthesia, and maintaining the condition in his confine- 
ments from six to fourteen hours. 

His object was analgesia, a semi-consciousness that 
should be painless ; not the more subtle but easier to regu- 
late amnesia, or forgetfulness of pain, which is the Dam- 
merschlaf . To prevent analgesia from passing into com- 
plete unconsciousness, under which labour can seldom be 
maintained indefinitely, required drop by drop watching. 
But this was not too much trouble for a humanitarian 
obstetrician to take. 

Chloroform came to be his favourite anaesthetic because 
of its superior convenience to administer and pleasantness 
to take, and after the confinement of Queen Victoria in 
1853 his small intermittent dosage came to be called 
chloroform a la reine. Some of his confinements read 
word for word like those under Dammerschlaf. 

In his first and subsequent reports on his results he 
stated positively that obstetrical anaesthesia could be ad- 
ministered without injury to mother or child. 

More particularly he says of its effect that more or 
less perfect immunity from pain was obtained, depending 
on the reaction of the individual patient, her tempera- 
mental response or "refractoriness." His first case shows 
the high degree of success he sometimes attained. 

Of the birth process itself he found that the birth 
contractions were not diminished, ether indeed often 



SO AUTHENTIC TWILIGHT SLEEP 

acted as a diffused stimulant and tended to regularise 
them. The doing away with inhibitory pain also made 
the mother more able to exert her voluntary muscular 
"labour" and, on the other hand, she did not make the 
spasmodic efforts by which a woman sometimes injures 
herself in the agonies of the end of a birth. 

Of Simpson's conclusions, Dr. A. Ballantyne, one of 
his successors as president of the Edinburgh Obstetrical 
Society, and himself an enthusiast for obstetrical anaes- 
thesia, said in 1897: 

"In exactly three weeks from his first case, he gave the 
results of his observations, which in all essential particu- 
lars have been fully sustained during the past fifty years." 

This statement we believe to be borne out by subsequent 
experience, though this experience has been scattered, Tin- 
standardised, and never intensively studied on a large 
scale, as has the experience in Dammerschlaf at the Erei- 
burg Frauenklinik. Indeed we believe Simpson to have 
had a better method of semi-ansesthesia and better results 
than many of those later obstetricians who sometimes 
availed themselves of his discovery. 

If obstetrics is still, as one obstetrician calls it, the 
"most traditional" of the sciences, the administration of 
chloroform in obstetric dosage is the most traditional of 
emergency ansesthetisation. Its use is so unstandardised 
that it is impossible to generalise on its effect; each user 
is a law unto himself, and judges its effects by his own 
results. 

Of the few women of the last generation who did hap- 
pen to know that they could with safety choose a painless 



HOW SIMPSON'S METHOD WAS KILLED 81 

birth, we remember one mother of ten whose last baby 
was born under chloroform a la reine. 

"Most of those who had this anaesthetic," says Simpson, 
"subsequently set out like zealous missionaries to persuade 
other friends to avail themselves of relief in their hour of 
trial and travail." This woman was no exception. She 
treasured the memory of this "perpetual blessing to 
women" until one of her girls grew up and married. Then 
came her chance to act the zealous missionary. Her daugh- 
ter was to have a child, and the doctor shrugged his 
shoulders when she demanded chloroform a la reine. So 
she gave it herself, and her daughter had as painless a 
spontaneous birth as an unexperienced administrator could 
give. 

The layman is almost dumb with amazement, in going 
over the experience with chloroform, to see how frequently 
it is administered by an amateur anaesthetist. One of 
the writers of this article has been called upon to admin- 
ister it for an obstetrician whose nurse was busy waiting 
on him and who had not his assistant at hand. 

A. Lapthorne Smith, in an address before the American 
Gynecological Society in 1911, advises alcohol-ether-chloro- 
form mixture and says that the patient can give it to 
herself, or the trained nurse can give it ; while J. W. All- 
wright says: "She (the patient) graduates, so to speak, 
the supply exactly to the demand, and in this way is pre- 
sented to the observation of the practitioner one of the 
most important and interesting agencies in operation for 
relieving suffering, sometimes agony, which he ever 
noticed." 

Though for reasons connected with her condition, i.e., 



82 AUTHENTIC TWILIGHT SLEEP 

increased blood pressure during pregnancy, and strong 
expiration and abdominal muscular action during labour 
— the dangers of chloroform are reduced to a minimum in 
the case of a parturient woman, its administration by an 
inexperienced layman can hardly be without dangers. But 
the actual administration of ether or chloroform a la reine 
throughout the last two generations, has ranged from cases 
like that of the mother who administered it to her daugh- 
ter, and the writer who administered it to her sister, to 
the maintaining of as delicate a condition as the Dammer- 
schlaf itself over a long period of time. The longest 
records are twenty-eight or thirty hours. 

Thus Havelock Ellis, the psychologist, uses as an illus- 
tration of dream phenomena, in his recent book, The 
World of Dreams, a Dammerschlaf produced by very care- 
ful administration of chloroform a la reine. 

This was a long and difficult first confinement. During 
the first stages alcohol-ether-chloroform (the "A.E.C. mix- 
ture") was given; later chloroform alone. 

"The drug," he says, "was not given to the point of 
causing complete abolition of mental activity, and the 
patient talked, occasionally sang, throughout; referring 
to various events in her life from childhood onward. The 
sensation and expression of pain were not altogether abol- 
ished, for slight cries and remarks about discomfort and 
constraint imposed upon her were sometimes mingled in 
the same sentences with quite irrelevant remarks concern- 
ing, for instance, trivial details of housekeeping. Con- 
fusions of incompatible ideas also took place as during 
ordinary dreaming. 'Where is the three-cornered nurse,' 
she thus asked, 'who does not mind what she does?' 



HOW SIMPSON'S METHOD WAS KILLED 83 

There was also the abnormal suggestibility of dream con- 
sciousness. The questions of bystanders were answered, 
but always with a tendency to agree with everything that 
was said ; this tendency even displaying itself with a cer- 
tain ingenuity as when, in reply to the random inquiry: 
'Were you drunk or sleeping last night?' she answered 
with some hesitation: 'A little of both, I think.' To 
the casual observer it might seem that there was a state 
of full consciousness on the basis of which a partial de- 
lirium had established itself. Yet on recovery from the 
drug there was no recollection of anything whatsoever that 
had taken place during its administration, and no sense of 
the lapse of time." 

This case was one of many in his experience. 

Here is a condition surprisingly like Dammerschlaf; 
not pain but the memory of pain is abolished, and the con- 
dition is checked and held in poise by observing the pa- 
tient's irrelevant talk, that "Memory Test," which is re- 
garded as the main objective aid in the maintenance of 
the Dammerschlaf. 

Dr. E. C. Buist of the Dundee Eoyal Infirmary, writing 
in 1907, indeed deliberately likens the Dammerschlaf con- 
dition, though not the method of attaining it, to obstetric 
anaesthesia under chloroform a la reine as he knows it. 
This condition of clouded consciousness is sometimes called 
chloroform inebriation. 

"Under this," he says, "the patient lies quietly in the 
intervals between her pains, wakes up" (or seems as objec- 
tively observed to wake up) "when they come on, and if 
she feels them, has no suffering, or if she has, is so little 
impressed by it that she immediately forgets it." 



84 AUTHENTIC TWILIGHT SLEEP 

One doctor writes as follows of present-day procedures : 

"As regards the common English method of using chlo- 
roform: one puts a little chloroform on a handkerchief 
in a tumhler and holds it to the patient's face, adding a 
little more chloroform from time to time as soon as signs 
of pain or discomfort appear. This proceeding seems to 
involve no special skill and is free from danger, whilst 
it is found quite satisfactory. When recollection of pain 
is left behind, it is probable that too little chloroform has 
been given. I use it in almost all my cases." 

The men quoted themselves use an analgesia such as 
Simpson attained, and some of them use it, as the last 
quotation shows, very frequently. This analgesia is ac- 
companied by loss of memory of the birth. Only in Ellis' 
experience, however, is a rambling conversation in which 
occurs confusion of incompatible ideas (the characteristic 
sign of Dammerschlaf ) noted. 

In long confinements many skilled and conscientious 
anaesthetists are afraid of the cumulative effect of too 
steady administration, which they fear will stop or retard 
labour. They, therefore, often merely aim at pain-lessen- 
ing (hypalgesia). Dr. J. P. Eeynolds, of Boston, an 
enthusiast for ether-seminarcosis expressly states that he 
never gives his patient as much relief as she begs for. 
Inhalation seminarcosis, though a blessing compared with 
painful labour, is described by him and many other doctors 
in objective terms which sound anything but ideal. It is 
often described by the mothers themselves as a long night- 
mare ; they remember some pain, though not in the inten- 
sity of full consciousness ; the subjective experiences they 
remember distinctly ; as one mother said in describing this 



HOW SIMPSON'S METHOD WAS KILLED 85 

state : "There may not have been so much pain. But the 
sense of helplessness that I had, seemed worse than full 
consciousness and ability to fight for myself." 

This is very different from the wiping o'f the whole 
incident of birth-giving out of a woman's life which 
characterises the Dammerschlaf condition or perfect chlo- 
roform inebriation. 

This hypalgesia has nevertheless been thought as good 
in obstetrical practice as analgesia. So little is the knowl- 
edge of the possibilities of obstetrical anaesthesia published 
and made the common property of all practitioners that 
their attitude runs from that of Ellis' resourceful and 
fearless administration over a long period, to the timidity 
of one authority who puts himself on record in these 
words : "As to chloroform a la reine, I do not know any 
one who would use it over a long period, but it is very 
useful where the distress begins within a short period of 
the probable delivery. We are now much more sensitive 
as to the danger of prolonged chloroformisation even when 
light." 

It is more than possible that some of the failures of 
chloroform a la reine are due to the fact that its use has 
never been thought of enough importance for its possibili- 
ties to be worked out intensively on a large scale, and its 
practice standardised and popularised. Unpathological 
pain in childbirth has been accepted philosophically by the 
profession at large, so that each man whose personal sensi- 
tiveness has led him to use semi-ansesthesia in his obstet- 
rical practice has had to learn its technique for himself 
by his own experience. If there existed as a matter of 
common knowledge in medicine, a technique that relieved 



86 AUTHENTIC TWILIGHT SLEEP 

him of the assuming of too great risks, the average obste- 
trician might avail himself of it and the average success 
obtained with chloroform a la reine might produce the 
condition of analgesia throughout the whole of a long, 
tedious birth such as Ellis describes. 

Simpson's attitude toward opponents of obstetrical anaes- 
thesia was uncompromising. 

"From a moral point of view," says he, "the refusal 
to relieve a woman in childbed of its sufferings seems to 
me to be a painful and terrible responsibility for a man 
who exercises so sacred a profession as that of medicine." 

The Royal Medical and Chirurgical Society put itself 
on record in 1864, when some 30,000 painless births were 
known, as believing obstetrical anaesthesia to be a safe and 
desirable procedure, if administered with the care expected 
of an obstetrician. 

Nevertheless five years later the obstetrical anaesthetist 
was evidently still persona non grata, for A. Ernest San- 
son apologised with some bitterness for having the temer- 
ity to urge artificial relief in childbirth. He begs 
the patience of the obstetricians to whom he is speaking 
for introducing an unpopular subject, but calls their atten- 
tion to their enthusiasm for surgical anaesthesia for the 
relief of pain, "which has its great exemplum in par- 
turition." 

The long thin line of men who have continued Sanson's 
fight for universal painless birth have not been able to 
conquer the ranks of conservative obstetrics. From time 
to time in obstetrical congresses or in the pages of obstet- 
rical journals, these men are heard from. They are almost 
invariably prominent men. Newell and Reynolds of Har- 



HOW SIMPSON'S METHOD WAS KILLED 87 

vard, and Davis of Pennsylvania, go so far as to say that 
if a sensitive patient cannot be narcotised, it is better that 
she should be delivered by Ccesarean section than that she 
should endure the agony and subsequent breakdown of 
birth in consciousness. Often the discussion is offered in 
the president's introductory address at an obstetrical con- 
gress. The wider use of obstetrical anaesthesia is invaria- 
bly urged with great warmth; the assertion is made that 
the choice of painlessness should be offered to every woman 
in childbed, and that this offer should be made without 
any deterrent suggestion that "it may stop labour." Those 
who urge it believe that every obstetrician, and every 
general practitioner who undertakes to attend confinements 
should be equipped to administer it, not as an interference 
but as an aid to spontaneous birth. 

Dr. J. W. Allwright says: "The necessity or advisa- 
bility of chloroform to facilitate labour should depend on 
the obstetrician; as a means of relieving pain it should 
depend on the patient." 

"Would that word of mine," says Dr. J. P. Eeynolds 
in an address delivered at the National Jubilee of Anaes- 
thesia but not published in the proceedings, "could convey 
the inestimable blessing of ether in all labour, and silence 
groundless excuses for its neglect. . . . 'Bless God for 
ether!' has burst from the lips of thousands of women. 
It might well be made the cry of countless thousands 
more." 

"Men declare that it wastes time," he says in another 
place, a but the time of the obstetric attendant is no longer 
his own; he may not condemn the extra half -hour that 
ether will now and again compel. His disapproval is of 



88 AUTHENTIC TWILIGHT SLEEP 

trivial importance. An objection like this has no weight 
unless it comes from the sufferer, and she was never known 
to advance it." 

One German, whose bibliography of the subject covers 
many pages and represents the literature of five languages, 
has collected the published experience with some dozen 
anaesthetics in labour. He ends with the conclusion that 
the reported facts in regard to chloroform, ether and 
scopolamin-morphin show them to be the only ones suited 
for use throughout a long period. 

The main objection that this writer finds to these three 
narcotics is not that their careful administration presents 
serious dangers, but simply that it demands for success 
infinite pains over a long period of time. This is the 
main reason why chloroform and ether are imperfectly 
understood and comparatively little used in childbirth. 

Quite as important as this writer's conclusions is the 
impression he leaves on the reader of the slenderness of 
the total published experience and the contradictoriness of 
results based upon small individual experiences with ether 
and chloroform. In such a showing the 5,000 cases of 
Dammerschlaf at Freiburg stand out as unique in ob- 
stetrics. Chloroform and ether have never been standard- 
ised by a large scale experience under uniform conditions 
because anaesthesia over the course of a normal birth has 
only by a small minority of obstetricians been thought 
worth the trouble. 

Dr. Ballantyne's address at the Edinburgh Jubilee of 
Anaesthesia is one of the many general statements by 
authorities of the first rank on the possibilities of inhala- 
tion seminarcosis in obstetrics. 



HOW SIMPSON'S METHOD WAS KILLED 89 

His analysis of the physiological causes, already stated, 
which in the hands of a responsible administrator make 
obstetrical anaesthesia practically without dangers in com- 
parison with surgical anaesthesia, is authoritative. 

These addresses bulk small, however, in the literature 
of the gynecologist. The doctors listen and let them pass 
without comment or discussion. A conspiracy of respect- 
ful silence has retarded the normal development of Simp- 
son's contribution to remi-anaesthesia. 

Simpson's experience has not died with him; instead 
it has been buried alive in the files of obstetrical journals. 
Only a few have practised his perfect method and his uni- 
versal use over long periods of labour. 

A general practitioner told us a short time ago that he 
had never used an anaesthetic in his obstetrical practice, 
except in cases which showed structural need of operative 
interference with the forceps. 

In his practice, he added, he had known but one woman 
unanaesthetised, who bore her child without pain. He did 
not say that the pain was physiologically necessary, but 
ho bore it, in the person of his female patients, with 
extreme philosophy. 

This gives a shocking evidence to the half-century-old 
words of Simpson, who said that his profession might 
never help him in his effort to spread the idea of universal 
painless childbirth. Many who conduct confinements to- 
day do not even know the possibilities of painless birth. 

But Simpson added, that "women would themselves 
betimes rebel against the usual tortures and miseries of 
childbirth." 

Eor two generations there has been no surgery without 



90 AUTHENTIC TWILIGHT SLEEP 

anaesthesia. For those two generations the right of women 
to painless childbirth has been withheld from them ; but it 
is only at this late date that the rebellion of which Simpson 
speaks has begun. 

But, delayed as it has been, the women's demand has 
come contemporaneously with the perfecting of that better 
narcotic, easier, safer, and pleasanter to take, to whose 
discovery Simpson constantly and hopefully looked 
forward. 



CHAPTER VI 
"Time Will Tell" : Berlin to Chicago 

"Dammerschlaf in obstetrics," says Gauss in 1911, as 
though laughing at his critics, "has one quality in com- 
mon with other methods, namely, that it was enthusias- 
tically welcomed by some, opposed and rejected with equal 
energy by others. We have now," he goes on, inviting a 
reopening of a battle whose last skirmish had been fought 
in 1907, "reached a new stage. We have statistics of over 
eight thousand births, of which three thousand were in 
the Freiburg Frauenklinik. These three thousand," says 
he, rubbing the challenge in, "furnish homogeneous statis- 
tical material to serve as a touchstone for the value of the 
methods used elsewhere." 

But the struggle to improve the standard of obstetric 
use which he began in Germany was not to be reopened 
till 1914; this time in America. 

Germany, the birthplace of obstetrical scopolamin-mor- 
phin, had heard enough about the subject, so she let the 
discussion drop. She was satisfied to let each physician 
use or not use that "dangerous drug scopolamin" accord- 
ing to his own individual decision and according to his 
own individual method. 

This is what England, the birthplace of chloroform and 
ether, had done with the efforts of Simpson and his f ollow- 

91 



92 AUTHENTIC TWILIGHT SLEEP 

ers who urged wider and better knowledge of these nar- 
cotics in childbirth. 

Contrary to the statements of many doctors, scopolamin- 
morphin in childbirth has never been discredited or 
discarded. 

Germany, counting in the large total at Ereiburg, must 
have to-day some twelve thousand scopolamin-morphin 
births, eight thousand of them under Ereiburg technique, 
largely as a result of the publicity of the great medical 
quarrel — Berlin University against Ereiburg University — 
of 1907. Every year many hundreds are added. 

After 1903 von Steinbuchel's obstetric use of scopo- 
lamin-morphin had spread quickly. There was a wildfire 
of experimentation. His twenty cases were assumed to 
have proved the perfect safety and the perfect efficacy 
of the obstetric narcotic. Later on after a series of mis- 
haps, the evidence of Gauss's thousand cases could not 
convince many that there was any method by which it 
could be safely and efficaciously used. 

Those who followed Steinbiichel's caution had encour- 
aging results. But many were not cautious; they used 
little skill and few precautions and had many accidents 
great or small. Scopolamin-morphin fell as quickly out 
of favour as it had come in; its record in major surgery 
was recalled and another cross put down against the drug. 

But its intrinsic merits were such that it could not be 
killed in either surgery or obstetrics. 

The combined narcotic, scopolamin-morphin, is a new 
one. Its first use goes back no farther than this century. 
Its history belongs largely to Germany. 

Casting around for some general anaesthetic which 



"TIME WILL TELL" : BERLIN TO CHICAGO 93 

should not have the steady death-rate of chloroform and 
ether, a group of German surgeons, among them Korff and 
Schneiderlin, of Freiburg, believed that in this they had 
found the ideal. 

These doctors used the combination hypodermically in 
huge dosage for major surgical operations, and had several 
deaths. 

They had overdosed, believing for reasons they set 
down in long contrasting columns, that the two drugs 
were perfect antidotes in their action on heart and respira- 
tion and in other respects. 

When the disillusionment came with the accidents 
scopolamin was held to be responsible, though the evidence 
turns out to be strongly against morphin. 

It is recognised now that there was a grain of truth in 
the ingeniously worked out theory of antidotes. Scopol- 
amin to some extent antagonises the depressing action of 
morphin on the breathing centres. 

To-day the use of the combination in major operations 
is abandoned, but it is found invaluable in small dosage 
as a preliminary narcotic to save the patient's terror and 
struggle in going under ether or chloroform. It is used 
in this way by all anaesthetists everywhere. In Crile's 
anoci-association by combining this drug with other ele- 
ments in his method, the inhalation narcotic can sometimes 
be eliminated entirely. 

These are the surgical uses of scopolamin-morphin, or 
scopomorphin. To be efficacious in obstetrics and oblit- 
erate pain without interference with labour it has to be 
used in a succession of infinitely small doses so far apart 



94 AUTHENTIC TWILIGHT SLEEP 

that any danger it may offer in surgery to circulation or 
respiration is reduced to a minimum. 

For all uses of this new and experimental drug during 
the last ten years the death-rate per thousand cases stands 
midway between the two old-established and well-known 
anaesthetics, chloroform and ether. When the ether death- 
rate is corrected by deaths from ether pneumonia, scopol- 
amin-morphin stands lowest of the three. 

It is, however, with its use and its mortality in obstet- 
rics that we are concerned. 

Among those who were not frightened away by others' 
accidents were, as we know, Kronig and Gauss. Instead 
they cautiously perfected their own use and, in 1906, not 
until he had a larger experience than any one who had 
yet reported, Gauss published his thorough study of five 
hundred cases. Its effect was to reopen a subject that 
was losing its interest. It reopened experimentation also. 

We now recognise that it laid down definite principles 
which made further reckless experimentation unnecessary, 
but many of its early readers did not care to see that point. 
Some did, however, and in 1911 a student collected the 
experiences of six men who had published reports on some 
twelve hundred births conducted under the conditions laid 
down by Gauss. These men express enthusiasm; and 
there were many other followers of Gauss besides those 
recorded in that group. 

But there were many others who did not attempt to 
follow Gauss. 

Gauss's first dose of .0003 to .00045 scopolamin and .01 
morphin was followed by a diminishing dose of scopolamin 
widely and irregularly spaced in accordance with the 




Sir James Young Simpson's sole and persistent work was with 
obstetrical semi-anaesthesia, or the attaining of painless spontaneous 
birth. "My profession may never help me," he said once, "but women 
themselves will betimes rebel against the usual tortures and miseries 
of childbirth." 




The First "Painless" Child. By chloroform a la reine Sir James 
Young Simpson maintained a Dammerschlaf condition from six to four- 
teen hours. 



"TIME WILL TELL": BERLIN TO CHICAGO 95 

memory test, morphin generally dropping out after the 
first injection. 

The dosage of those who saw no more in Gauss's 1906 
report than that it was favourable to scopolamin-morphin 
and that it covered as many as irve hundred cases, ranged 
from .0001 to .002 scopolamin, from .01 to .02 morphin 
for the first dose ; successive doses not infrequently repeat- 
ing the morphin and being spaced either at set intervals 
or as the doctor saw objective signs of pain. They made 
no use whatever of the memory test. 

Overdosing was heavy under these conditions. The stu- 
dent above referred to finds over twenty of this class 
of report covering not quite two thousand cases, and Gauss 
refers to others. 

They show frequent and excessive prolongation of labour 
resulting sometimes in asphyxia of the child. There is 
much oligopnea also. In some cases there was stoppage 
of labour. In others there were reported hemorrhages, 
calls for the forceps to end the birth quickly, and other 
disagreeable results. In all this experience and in the 
earlier obstetrical experience with scopomorphin, however, 
in Germany, the country of careful death records, there is 
no record of a mother killed. Six children dead were 
charged to scopolamin-morphin but reference to their 
autopsies shows in all but one, amply sufficient cause for 
death without holding the narcotic to blame. That one 
(Dr. Bass's case) showed symptoms of morphin poisoning. 

It is strange, or perhaps it is in reality a tribute to the 
safety of "that dangerous drug scopolamin," that reckless 
experimentation had no more victims than this. 



96 'AUTHENTIC TWILIGHT SLEEP 

This account will show that the fight to be fought was 
not for the drug but for the right use of the drug. 

This came out clearly when Berlin University pitted 
itself against Freiburg. 

It is not necessary to go into the unscientific side of 
scientific quarrels. It is enough to quote the local prac- 
titioner near Freiburg who told us that the reason Dam- 
merschlaf did not spread but remained almost strictly 
localised, was the jealousy of the Berlin Medical School. 
"If Berlin had originated it," he said, "it would now be 
the practice of all Germany." 

It was he also who told us a piece of local gossip to 
the effect that Dr. Hocheisen, who was sent by the great 
Geheimrat Bumm of Berlin to study Dammerschlaf, spent 
six weeks out of his allotted two months' study on the 
Feldberg Mountain on the outskirts of Freiburg at the 
winter sports. That may be idle gossip too mean to repeat. 
At any rate Hocheisen did stay long enough down in the 
valley at the Frauenklinik to get a real contempt for a 
method of alleviating the mother's pain that was a "torture 
to doctor and nurse." 

Fortified by his experience he returned to Berlin Klinik 
and went to work. Soon he had one hundred cases to 
report on, and at the next meeting of German gynecolo- 
gists the two universities clashed. Gauss now had one 
thousand cases. His tables showed the dosage more per- 
fectly adapted to the individual needs of the mother and 
child. The percentage of oligopnea, for one important 
thing, was cut in half. In no respect had the method 
fallen behind; in most respects it had improved. 

With his hundred Hocheisen expressed disappointment. 



"TIME WILL TELL": BEKLIST TO CHICAGO 97 

He paved the way for disappointment in his preliminary 
statement, hy his melancholy account of the drug he used. 
It is strange, he says, "to hear praised a poison so incal- 
culable in its effects. It is used by alienists," he continues, 
showing that one effect is evidently calculable "to replace 
the obsolete strait- jacket." And so he goes on painting 
luridly the worst the drug can do. As Gauss says of an- 
other critic, this was no hospitable spirit in which to 
undertake work that needed sympathy and adaptability 
for success. 

Passing on to his cases Hocheisen says that though the 
majority were successful in some alleviation of pain many 
bad effects were observed, labour was frequently unduly 
prolonged, forceps had to be used in a large percentage of 
cases and could, he generalises, have been used in a great 
many more. Postpartum hemorrhage was frequent and 
so were deeply apneic babies. 

Gauss's directions were, he assures us, followed in every 
particular — except for the minor detail, that his entire 
technique had to be abandoned as hairsplitting and compli- 
cated and that the conditions of a large charity hospital 
made it impossible to adapt the environment properly. 

Inquiry into his dosage shows that in other particulars 
also Hocheisen deviated from Gauss, using for the most 
part but one dose; this one dose was in many cases very 
large, going as high as .0009 of scopolamin and even occa- 
sionally .002. Abandoning Gauss's memory test, his cri- 
terion for success had been objective signs of painlessness; 
and these, as Gauss pointed out, are always signs of over- 
dosing. Test of his preparation of scopolamin proved 



98 AUTHENTIC TWILIGHT SLEEP 

that it had not, in those days when no stable preparations 
existed, been freshly prepared, and it had gone bad. 

As Gauss's analysis of Hocheisen's report brought out 
one after another of these defects and deviations from 
the model, Hocheisen was driven from sober exposition to 
irritated generalisations. He ended with an angry look 
into the future. 

"We shall probably never agree," said he. "The future 
will show who is right. If seopolamin remains Gauss will 
be right. If it disappears I shall be right. Time will 
tell." 

With these historic words he ended the famous debate 
of 1907. He had set up a man of straw as Gauss's method, 
and had knocked his man of straw down. But fortunately 
the real man had been present to point out the fraud. 

Harm was done, probably more harm abroad than at 
home, because many of those who had heard the debate 
learned from it the real technique. To-day there are scat- 
tered throughout Germany hospitals using the Ereiburg 
method with a total of many thousand cases. The head 
of one of these hospitals says in defiance of Berlin: 

"We have here a means, if the physician does not grudge 
the time, which without appreciable loss in vigour of 
pains, without danger to mother, or injury to child, enables 
us either to completely abolish apperception of pain in 
confinement, or to reduce it to a minimum." 

But the main great clinics tried their experiments in 
Ereiburg technique in the manner of Berlin, and with like 
results. Stefien, of Dresden, who enjoyed a woman's pain, 
entered upon it in that spirit, carried it out in a crowded 
clinic with complete disregard of amount and very per- 



"TIME WILL TELL": BERLIN TO CHICAGO 99 

functory following of the method of the Freiburg dosage. 

This Steffen was a sensitive man. His report is domi- 
nated by his nervous concern for the unpleasant impres- 
sions a painless birth may make on his interns and mid- 
wives. He deeply grieves for his head midwife, who tells 
him frankly that after fifteen years of midwifing, all this 
nonsense of women half under an anaesthetic, some excited 
and requiring constant watching, all irrelevant in their 
talk and indifferent to their surroundings, is highly 
"unsympathetic" to her. 

He did not trouble his interns much with the memory 
test, and he did not protect the patients' senses from dis- 
turbance by blue glasses or antiphones "out of considera- 
tion for the assistants, because of the repulsiveness of the 
picture presented." 

The other main critics, Gminder and Avarffy, in every 
respect patterned not on Gauss but on Hocheisen. They 
went even further, for they repeated the full dose more 
often than he, including the morphin. All confessed that 
they undertook the experiment unwillingly, in response 
to popular demand. Their methods show them either 
determined to fail, or too stupid to understand the Frei- 
burg technique. 

Leaving it in words for time to decide, Herr Bumm, 
of Berlin, and his allies from the other great city clinic 
nevertheless believed that they had settled the matter of 
the value of Freiburg Dammerschlaf for good. 

The setback they gave to it was not final, but it was 
most important ; nowhere more so than in America. 

France was not much affected. She had quickly run 
through her own experience with scopolamin-morphin, and 



100 AUTHENTIC TWILIGHT SLEEP 

most French obstetricians had discarded it. When we 
read that one of them used a dose four times as large as 
Steinbiichel's we are not surprised at some disappoint- 
ments. In 1911, however, Lequeu was still recommend- 
ing it. 

English experimenters were few, and mostly cautious. 
They adhered to Steinbuchel's dose, contenting themselves 
with mere lessening of pain, as some physicians use chloro- 
form and ether. Dr. Buist, of Dundee, has used it in this 
way in the majority of his cases since the early days and 
it has spread from him to many other physicians in 
Dundee. J. Halliday Croom was still using it and report- 
ing his enthusiasm as late as 1909. 

Neither France nor England was much affected by 
Gauss's work, except to quietly note and reject his difficult 
technique. 

America was strongly affected by the discussion at 
Berlin. 

When we expressed to an American doctor our regret 
that our work had caused attacks on the Freiburg doctors, 
he laughed. "Injured the Freiburg doctors!" he said. 
"You have disinterred the Freiburg method. We took our 
judgment of medical matters from Berlin, and Berlin 
opposition and misrepresentation had successfully closed 
the subject for us until you reopened it." 

This has been our own judgment from reading the 
literature on both sides of the ocean. 

With the early days of Steinbiichel it had been taken 
up over here, unstandardised and haphazard. 

There had been discouragement, but when Gauss's re- 
port came in 1906 work began again. This is the work 



"TIME WILL TELL": BERLIN TO CHICAGO 101 

that has come to be spoken of as the Chicago experience 
because in newspaper interviews several Chicago doctors 
have recently spoken of their adverse experience, and 
because of a personal incident. 

Standing at the bedside of a woman just delivered in 
the American Hospital in Paris one of us first heard of 
the Chicago experience, in such a manner as to fix it in 
her mind under that name. She had recently come from 
her sister's painless confinement at Freiburg to this 
friend's very different experience. A weak voice came 
from the pillow: "It was short, thank God; it was hell 
while it lasted." 

From a room nearby came the groans and cries of an- 
other woman in "her hour." 

The visitor's nerves were overwrought by a situation 
which seemed to her now so harrowing and so unnecessary ; 
she had come from the clinic known to American medical 
men, she found later, as the most humane in Europe. 

"How can you stand this ?" she asked the young doctor 
at the bedside. "Don't you know the scopolamin Dammer- 
schlaf at Freiburg ?" 

He glanced at her as a young doctor glances at a hys- 
terical fool of a woman. 

"Oh, that," he said. "We tried that out in Chicago 
years ago, and it was no good." 

He waved his hand at the woman on the bed. 

"She didn't have any kind of a hard time," he said. 
"She's all right." 

It was the first of many times that we were to hear the 
whole Freiburg experience discounted in a phrase; so 
Chicago stands for much to us. 



102 AUTHENTIC TWILIGHT SLEEP 

It seems to have been a matter for open discussion in 
Chicago at the time, for club members remember their 
doctor friends discussing Gauss's reports. They remember 
also talk of Hocheisen's report, and the Chicago doctors' 
growing discouragement with their own results. 

Experimentation with scopolamin-morphin in child- 
birth was in reality countrywide; with each phase of ex- 
perimentation in Germany, it spread to America. Dr. 
Charles M. Green, Professor of Obstetrics at Harvard, 
took it up after Steinbuchel. His results did not satisfy 
him, and he appears to have taken no part in the later 
work that followed Gauss's report in 1906. 

How extensively Gauss's report itself was read in Amer- 
ica it is impossible to say, but in the medical reviews 
there appeared short digests. Dismissing the technique 
with a sentence or a phrase, they brought out the fact that 
the Freiburg Frauenklinik had now had an experience of 
five hundred cases, which it reported having delivered with 
no injury to mother or child and with no interference with 
the birth process. 

The figures alone impressed; experimenters looked no 
deeper. 

They used the drug combination as though the amount 
or proportions were of no importance. We are told that 
scopolamin, of which Gauss's first injection ran, in Ameri- 
can terms, from 1/200 to 1/130 of a grain, decreasing in 
later doses, was given in America sometimes in as large 
doses as 1/75 gr. with no decrease in the amount at the 
second dose. The inferior and less dependable hyoscin 
they used more often than scopolamin. Morphin was re- 
peated in 1/6 to 1/4-grain doses as often as the scopol- 



"TIME WILL TELL": BERLIN TO CHICAGO 103 

amin. John O. Polak, Professor of Obstetrics in Long 
Island Medical College, who took part in the experimen- 
tation of this period, believes that mother and child could 
not have failed to be heavily morphinised by such doses. 

From overdosing with one or the other drug there were 
many accidents. Halpenny, Vrooman, Hies, C. B. Reed 
of Chicago, W. H. W. Knipe of New York, Barton C. 
Hirst of the University of Pennsylvania, and J. C. Apple- 
gate of Philadelphia were among those who reported un- 
favourably. 

In Germany it will be remembered no mothers were 
lost and but one child. In America where post-mortems 
are in most cases lacking it is impossible on the pub- 
lished evidence to prove any deaths. Long ago Simpson 
said with bitterness that all deaths not easily accounted 
for would be ascribed offhand to the anaesthetic he used in 
childbirth. And to-day the doctors' statements range 
from "many mothers and children lost" from scopolamin- 
morphin to Dr. Applegate's conservative statement that he 
had "many unpleasant effects on mother and child." Dr. 
G. F. Butler comments on the fact that though the dosage 
was reckless and such as to invite disaster, it seems as if 
the reporters must have spoken at random of their mishaps 
to mothers and children. For in 1906 when he under- 
took to gather in records of the contemporaneous ex- 
periences, he found out of at least one thousand births 
only nine deaths of children reported by H. C. Wood, and 
no deaths of mothers. Of Wood's cases only one had a 
postmortem, and in this case, says Butler, "we are asked 
to believe that advanced fatty degeneration resulted from 
a single administration of the ansesthetic." 



104 AUTHENTIC TWILIGHT SLEEP 

At this time Butler comments on the recklessness of the 
dosage prevailing among experimenters, and wonders at 
the lack of a proved death-rate. In 1911 Hatcher says 
frankly that no deaths have been proved against scopol- 
amin-morphin in American obstetrics. 

But overdosing introduced enough disagreeable elements 
into the births for Hocheisen's report in 1907, based as it 
was on the same ignorance as their own of the Freiburg 
technique, to be welcomed with relief in America as clos- 
ing for good any attempts to make use of scopolamin- 
morphin in spontaneous birth. Berlin, the first medical 
university of Germany, had — it is true, on the slim show- 
ing of a hundred cases — settled for good and all the claims 
of Freiburg for scopolamin-morphin, the one thousand 
Freiburg cases to the contrary notwithstanding. 

Doctors Polak, Knipe, and Beed and Drs. Harrar and 
McPherson of the Lying-in Hospital have within the last 
few months resumed the use of scopolamin-morphin, using 
true Twilight Sleep technique, and they report none of 
their former mishaps. The doctors at the Lying-in Hos- 
pital have already been quoted in regard to the former 
disregard of the Freiburg technique. 

In the general abandonment of scopolamin-morphin 
there remained a few obstetricians who persisted in its 
use. They had always respected their drug, had always 
been cautious with it. They had used it so that it could 
do no harm and had found it useful. In 1911 it was still 
being written of in the medical journals. Among the 
obstetricians who persevered were Bertha von Hoosen, of 
Chicago, and Franklin S. Newell, of Harvard. These in 
their practice kept up the tradition of this drug in child- 



"TIME WILL TELL": BEKLIJST TO CHICAGO 105 

birth. Neither used the Freiburg method, but both used 
judgment. When the safe Freiburg method of use was 
in 1914 really placed for the first time before medical 
and general public there were these medical men and 
women to vouch from their own long experience that 
scopolamin-morphin could be so safeguarded that it could 
be used in obstetrics without detriment to the mother, the 
child, or the birth process. 



CHAPTEK VII 

Time Has Told : Feeibttbg to New Yoke: 

In October, 1913, Freiburg in the person of Kronig and 
Gauss came to New York and offered its secret of painless 
birth to the doctors, who rejected it. In October, 1913, 
New York, in the person of two women who wanted that 
secret, went to Freiburg, which would have rejected them 
if they had not had infinite patience to get by indirect 
means for the women of America what the Freiburg doc- 
tors were offering freely to American doctors. 

In May, 1914, one of Kronig's American addresses on 
Dammerschlaf, delivered the preceding October, was pub- 
lished in Surgery , Gynaecology and Obstetrics. It caused 
no more comment among the doctors than when it was de- 
livered. In May, 1914, appeared in McClure's Magazine 
an article on Dammerschlaf prepared by one of the Amer- 
ican women at Freiburg in collaboration with a friend in 
New York. Within two weeks a woman had started for 
Freiburg on its recommendation. Within a month it was 
talked of by women from Maine to California. 

To us who remained in Freiburg till September there 
came occasional clippings and occasional personal letters. 
The clippings were from Vienna, London, Paris, and all 
parts of America. They showed that the world was on 
fire with the news, but how strong the flame was we did 

106 



TIME HAS TOLD : FKEIBUKG TO NEW YOKK 107 

not find till later. Medical clippings showed that the pro- 
fession at that time believed that it could be extinguished 
by ridicule and contempt without serious argument. 

Meanwhile, all classes of women of all grades of intelli- 
gence were taking the subject with a dead seriousness 
which paid no attention to ridicule and counted at their 
true value outcries of Friedmanism. 

They recognised that the figures of Gauss's ten years' 
work spoke for themselves ; that the work at Freiburg was 
not a "fake," and not an experiment, but a proved ex- 
perience and a method by which the whole medical pro- 
fession could profit, for their benefit. 

During the summer a few women wrote to us to answer 
questions so that they themselves could be equipped to 
answer their physician's hints of danger or quackery. 
More than one wrote that when she asked her doctor about 
Twilight Sleep he "got angry because a dozen women had 
been bothering him." 

But it was not till we came back in the fall that we 
found in conversation and in public meetings how intelli- 
gently American women had been equipping themselves 
on the subject of painless birth and what pitifully wise ob- 
stetricians they had become from personal experience in 
painful birth. 

By that time the first outburst of excitement had been 
succeeded by a more permanent interest. It was firmly es- 
tablished as a widespread and persistent though unorgan- 
ised demand for painless birth. It had become the most 
universal "woman's-rights movement" that has ever been 
conceived. 

The humanising of life-giving was the only news in 



108 AUTHENTIC TWILIGHT SLEEP 

periodical literature which had survived in competition 
with the news of the brutalising of humanity by life- 
destroying war. The two things stood out strikingly 
against each other, one representing the hopeful future, 
the other the hopeless past ; one representing the obedient 
acceptance of military authority by men, the other repre- 
senting the repudiation of medical authority by women. 

All over the world of medicine a few intelligent physi- 
cians have persisted in their use of scopolamin-morphin in 
birth since, after a period of reckless, haphazard use, it 
was given up by the profession in general a few years ago. 
Most of these have contented themselves with a cautious 
use that served in most cases merely to lessen pain. Few 
of them used it universally, in all births. We might have 
found Freiburg one of a hundred or more lying-in places 
where this cautious and partly successful use had survived. 
We did, as it turned out, find it the place where the science 
of obstetrical anaesthesia had been worked out to a per- 
fection that set a standard for the world. We could place 
the Freiburg technique, a "touchstone on which all other 
uses of scopolamin-morphin could be tested," in the hands 
of the women of America. 

Equipped with this standard, they persisted in their 
demand and by the fall the medical profession had passed 
from damning criticism to very extensive experimentation ; 
much of this has been carried on, as far as published re- 
ports show, with an open mind and a conscientious follow- 
ing of the Freiburg technique as far as it can be learned 
from Gauss's published reports without residence at Frei- 
burg. The medical journals had passed from ridicule to 
serious consideration. 



TIME HAS TOLD : FREIBURG TO NEW YORK 109 

The story of the attitude of American medicine towards 
the popular telling of a medical secret which rigid adher- 
ence to medical channels of publicity in Germany had 
almost killed is well worth telling. German women clam- 
ouring for information had got no satisfaction and the 
German medical press was absolute. The story in Amer- 
ica is very different, because the women knew. It is not 
told in any spirit of abuse, but to show how without an 
informed public many good things can be bullied out of 
existence by professional attacks which have no weight of 
reason behind them. 

It must be said that looking back over the whole story, 
after the first anger, the response of the medical profes- 
sion has been in most cases the response of people whose 
minds are both broad and simple. But without the women 
the first anger following upon the indifference physicians 
had shown to Kronig's own testimony, would have checked 
the Dammerschlaf in America as effectively as it had 
been checked at home. 

The ground for the first attack was anger and disgust 
at the violation of medical ethics. Physicians did not be- 
lieve that without the doctor's connivance non-professional 
women could intelligently gather information from pub- 
lished scientific sources. Discounting on these grounds of 
self-advertising the value of the special contribution of 
the Freiburg practice, there was left a real fear of this 
popular recommendation of powerful drugs. If they were 
in the mood to discount the value of the technique, the 
fear is understandable. It is this which in the mind of 
the conscientious physician puts medical reserve next in 



110 AUTHENTIC TWILIGHT SLEEP 

importance to the promises and prohibitions of the Hip- 
pocratic oath. 

It is difficult for an outsider to grasp the sanctity among 
physicians of this idea. The avoidance of general pub- 
licity in medical matters until the particular contribution 
has become a matter of general practice seems to us to 
offer more dangers than safeguards. It gives the profes- 
sion a supreme power to kill or let live things of vital 
general interest. This has been recently pointed out in 
two medical journals and the campaign for Dammerschlaf 
was the occasion. Medicine is full of discoveries that had 
to be rediscovered because they were killed by the pro- 
fession. Oliver Wendell Holmes was laughed at, Semmel- 
weis was driven insane, and a whole generation of women 
were deprived of the benefits of asepsis in childbirth, be- 
cause there was no body of outside opinion to support these 
physicians in their work. Medical publicity to the out- 
sider seems to-day to have saved another blessing in child- 
birth from being delayed another generation or more. 

"Quite naturally," said American Medicine a few 
months later, "this publicity roused a storm of protest on 
the part of a medical profession accused of backward- 
ness." Obstetricians would not believe that a popular 
magazine article contained facts new to them. They 
judged that Freiburg had a record and a practice like 
their own with scopolamin-morphin, and their own record 
had been so unsuccessful that they feared new experimen- 
tation, especially by ill-equipped general practitioners. 
The general practitioner who criticised, protested for other 
reasons. He had read the magazine article, learned the 
technique that the drug demanded, and knew that as the 



TIME HAS TOLD : FREIBURG TO NEW YOEK 111 

cost of childbirth was rated by his patients he could not 
afford to give it. 

Pear, then — fear of dangerous experimentation on the 
one hand, fear for the loss of his patients on the other — 
made the obstetrician and the family doctor combine at 
first to try to laugh the new medical "craze" out of ex- 
istence. The first criticisms in medical journals were 
intemperate and often entirely irrelevant. They had no 
effect on the public interest, and this method of attack has 
not survived except in an occasional letter by the local 
practitioner to a provincial, newspaper. 

No medical journals were more intemperate in their 
first attacks than the New York Medical Journal and the 
Cincinnati Lancet Clinic, 

In May the Journal called the Dammerschlaf a quack 
scheme and the magazine writers advertising-copy writers. 
In the early fall it published an announcement that the 
Dammerschlaf was not the peculiar proud possession of 
Freiburg alone, but had been used for some time in the 
Jewish Maternity Hospital in New York City. We can 
forgive the Journal for withholding the further fact that 
the method had been undertaken in this hospital early in 
June by a former Freiburg intern to justify the claims — 
made in the popular magazine — for the Freiburg tech- 
nique. It is enough that by this announcement and by 
later publishing a report on a series of cases in this hos- 
pital the Journal raised the Dammerschlaf in the estima- 
tion of its readers from a quack scheme to a recognised 
medical procedure. Its wholesale condemnation had given 
way to qualified support. 

Contemporaneously with the New York Medical Jour- 



112 AUTHENTIC TWILIGHT SLEEP 

noil, the Cincinnati Lancet Clinic published an attack in 
its correspondence columns in terms more dignified but no 
less sweeping. Scopomorphin had been tried and dis- 
carded in obstetrics. Editorially it has not, since then, 
let the subject drop. Put upon the defensive by the ac- 
cumulating evidence that there was good in the Dammer- 
schlaf and that the early medical judgments on it had been 
ill-conceived and reactionary, the Clinic made the protec- 
tive editorial statement "that the medical profession is 
progressive and not conservative is well known to all its 
members." On that progressive platform it published the 
next month Dr. Magnus A. Tate's report on what work 
had been done with Dammerschlaf in America from June 
to September. Subsequently it published the report of 
the Lying-in Hospital in New York, and later still it 
published an editorial which is one of the finest of recent 
estimates of the place of scopolamin-morphin in surgery 
and obstetrics. It begins with the statement that "it is 
hard to understand the latter-day dread of scopolamin" 
and ends with the recommendation of extreme caution in 
the use of morphin, for "scopolamin is as safe for infants 
as for adults." These might almost be the words of Gauss 
of Ereiburg. Caution in the use of morphin is one of the 
essentials of the Freiburg method. 

Many of the early criticisms, themselves offered in the 
form of criticisms of Gauss, simply echoed Gauss's own 
criticism of unstandardised use of scopolamin-morphin. 
"Painless childbirth declared obsolete" is the curious news- 
paper headline given to a column on a criticism of this 
kind by the Journal of the American Academy of Medi- 
cine in June. The criticism emphasises like Gauss the 



TIME HAS TOLD : FKEIBUKG TO NEW YOEK 113 

necessity for going slow on morphin, and dwells like 
Kronig himself on the necessity for a trained obstetrician 
and a hospital environment for safe, and successful obstet- 
rical work with scopolamin-morphin. Nevertheless it 
leaves, and it is designed to leave, the impression that it 
takes exception to Gauss and Kronig, trying to confuse 
their method with unsafe and unsuccessful ones. 

So Barton C. Hirst, Professor of Obstetrics in the Uni- 
versity of Pennsylvania, writing in the Ladies 9 Home 
Journal, tries to make the Freiburg method appear an un- 
successful makeshift adaptation of a method that had 
failed. 

"This treatment/' he says, "was used in the maternity 
of the "University of Pennsylvania in a series of 
cases over a period of two years. My experience of 
it coincided with that of my colleagues in this and other 
parts of the world. If enough morphia is given to abolish 
pain there is danger. . . . In 1912 I had the pleas- 
ure of observing this method at Freiburg. . • . It 
was interesting to hear that the morphia was employed in 
a single moderate dose, followed by small quantities of 
scopolamin. Evidently the disadvantages of the treatment 
. . . had necessitated this modification." 

Dr. Hirst further enhances this idea of the makeshift 
nature of the Freiburg procedure by stating that he does 
not believe that the successive doses of scopolamin given 
abolish pain, but that the patients "being told afterwards 
that they had no pain, left the institution impressed with 
that belief." In this belief that a large part of the pain- 
lessness at Freiburg is attained by working on the patient's 
credulity, Dr. E. Gustav Zinke appears to agree with Dr. 



114 AUTHENTIC TWILIGHT SLEEP 

Hirst. Dr. Hirst would have some trouble in making a 
Freiburg mother believe this, after she had had one expe- 
rience of waking incredulous to find her baby already 
born. 

Criticism by ridicule and criticism by such subtle dis- 
tortion and distraction of the reader's mind as this were 
not the only early forms. 

Among the many important gynaecologists who freely 
expressed their adverse opinions in the general press 
though the press was taboo for extended favourable opin- 
ions, as one or two physicians found, most expressed them- 
selves in wilful disregard of what was being done at Erei- 
burg, but with a very clear memory of their own failures 
years ago with scopomorphin. Dr. Charles M. Green of 
Harvard had an experience in 1903 before the Ereiburg 
method of Twilight Sleep was even thought of. Never- 
theless, he bases his adverse criticism entirely on this 
early experience of his own, and he has informed himself 
so little on the distinctive characteristics of Twilight 
Sleep that he roughly calls his own use Twilight Sleep. 

When asked what she thought of Freiburg Twilight 
Sleep, a Chicago obstetrician answered briefly: "I used 
scopomorphin in twenty cases some years ago and was not 
pleased with my results." 

The peculiar empirical quality of the medical mind 
made it hard to divert it from personal experience. Most 
of the obstetricians would not at first accept the contribu- 
tion of Freiburg, because they could not at first grasp the 
fact that Freiburg had made any contribution. 

But even in the early months, lost sight of in the more 
spectacular headline-making criticisms, are on record the 



TIME HAS TOLD : FKEIBUKG TO NEW YOKK 115 

judgment of a few obstetricians that Freiburg probably 
had a better method of procedure to offer than they had 
known. 

And among those same early critics who had used scopo- 
morphin and who felt called upon to put their disap- 
proval on record there were not a few who changed their 
opinion later. Dr. Ross McPherson of the Lying-in Hos- 
pital, E"ew York, is one of these. 

"Undertaken rather in a spirit of scepticism," says Dr. 
McPherson, in the introduction to his report with Dr. 
Harrar on a series of 100 cases delivered under Dammer- 
schlaf between June and September, "the present investi- 
gation was begun by us several months ago. Doubtless 
many others have shared our recent experience in being 
the recipients of inquiries on account of recent sensational 
articles in the lay press on 'painless childbirth.' The first 
attitude was naturally to ridicule the whole matter as 
preposterous. . . ." 

He reviews the unsuccessful American experiments and 
the dropping of the drug, but recalls to his readers' atten- 
tion Kronig's re-awakening of the subject in the fall of 
1913, though it fell at the time on deaf ears. 

"It is scarcely possible that the distinguished head of a 
reputable German clinic would presume to publish suc- 
cessful results of a method in over 3,000 cases unless there 
was some virtue in it." 

It needed the sensational magazine article to bring this 
tardy afterthought. But never mind that ; it is the after- 
thought that is important. 

"It was," Harrar and McPherson go on, "entirely with 
an open mind that we approached the experiment, wishing 



116 AUTHENTIC TWILIGHT SLEEP 

to ascertain to our own satisfaction to just what extent we 
could condemn or extol the merits of the treatment." 

Then they call their readers' attention to the important 
point we have mentioned. It is worth repeating. 

"A phenomenon as interesting as the Twilight Sleep 
itself is that detailed descriptions of the technique which 
have been followed closely in this study have lain idle in 
the literature for six years with no one taking advantage 
of them. Those who did make trial of the procedure" (the 
narcotic, that is) "wandered far afield both in method and 
in the object to be obtained." 

By the time this was written, in September, there were 
probably few obstetricians who still criticised the Dam- 
merschlaf on the basis of their own past experience ac- 
quired before they knew of the Dammerschlaf. But Drs. 
McPherson and Harrar are the only ones to put the mis- 
take on record. 

Aside from reports on experience, the recent statements 
from physicians have been either informing like Dr. 
Evans' article in a Chicago newspaper or carefully criti- 
cal. There is more respect for the other side evidenced. 
Many of the statements of opponents in the Symposium in 
the Medical Times for December were warnings in regard 
to the great skill and care with which scopolamin-morphin 
has to be administered. With the accent different, as a 
demand that these safeguards of care and skill shall be 
supplied, many of these criticisms might have come from 
Kronig or Gauss themselves. They, like their critics, de- 
mand the hospital, the best and the most stable preparation 
of the drugs, the skilled and responsible and experienced 
obstetrician ready to meet all the emergencies of a birth. 



TIME HAS TOLD : FKEIBUKG TO NEW YOEK 117 

It is no more than this that Franklin Newell of Harvard 
means when lie states warmly that only the most skilled 
interns can administer scopolamin-morphin in childbirth. 
They consider at Freiburg that it takes two years to give 
an intern the general and special training which would 
make it possible for him to conduct a sleep unsupervised 
by his superior. 

The obstetricians' fear of the ill-trained general practi- 
tioner has been spoken of, and with it the recognition by 
many general practitioners that the technique of Dam- 
merschlaf was beyond their power to give on their stipend. 
The women requiring Dammerschlaf of their doctors know 
the technique and demand it. They know it so well that 
the idea of the hospital environment is growing more and 
more popular. For this very reason perhaps the general 
practitioner is taking his patient's demand the more seri- 
ously. 

The scores of unknown doctors whose Twilight Sleep 
cases appear in the newspapers are not altogether in the 
position that the apprehensive obstetrician has in mind. 
When obstetricians used scopolamin-morphin some years 
ago they knew nothing about it. To put it freely in the 
hands of the general practitioner on those terms would 
have been alarming. But to-day the general practitioner 
in America and his woman patient have as guide the Frei- 
burg technique, which reduces the dangers of scopo- 
morphin to a minimum. 

When Dr. Magnus A. Tate reported to the Cincinnati 
Medical Academy in 1914 on the first experiences with 
Dammerschlaf births in America he did not go to Gauss's 
1906 report for his description of the technique. He 



118 AUTHENTIC TWILIGHT SLEEP 

quoted from the extensive descriptions in the popular 
magazines and these same guides against bad usage are 
easy of access to all doctors. 

But we do not mean to underestimate this danger from 
the unskilled. We are doubtful whether the general prac- 
titioner, with his three confinements to his credit in his 
medical course, is competent to conduct confinements, 
whether painless or painful, with all the emergencies that 
they may involve. One of the most useful things that the 
campaign for Dammerschlaf has done is to bring out the 
need for better obstetrics. 

In response to this new demand, some general practi- 
tioners are raising their price for confinements and mak- 
ing themselves more proficient in this work. One whom 
we know of has taken extra study in obstetrics and is 
branching out as a specialist in Dammerschlaf, a work 
parallel to that of the anaesthetic specialist of whom a gen- 
eral medical training is required. 

Taken altogether, we do not believe that the general 
practitioner with the standard of the Dammerschlaf be- 
fore him and his patient can do more harm with scopo- 
morphin than, if as much as, the obstetrical specialists 
all over the world did a few years ago when they experi- 
mented with scopolamin-morphin as a new drug. 

Equally prominent with Dammerschlaf births in the 
newspapers throughout the summer was the exodus of 
American doctors to Freiburg. It began almost as soon 
as the woman who went there experimentally early in 
June, "fleeing from the ills she knew in her previous 
births to take her chances with the Twilight Sleep." One 
of the first obstetricians to go was this woman's doctor. 



TIME HAS TOLD : FKEIBUKG TO NEW YOEK 119 

His report on the Twilight work he did after his return 
should interest all women. This sending of the doctors is 
the first big thing the American women accomplished by 
their persistent demands on individual doctors. 

"Listen," said one physician who was asked how he 
came to go to Freiburg. "I could not help going. I was 
in Berlin, and I received no less than six copies of one 
magazine from my patients with instructions not to show 
my face in America until I had been to Freiburg." 

With the first public exploitation of Dammerschlaf, 
many were the hints of commercialism; of the women 
who would migrate and pour American dollars into the 
modest till of the University of Baden Frauenklinik and 
the pockets of the two Freiburg doctors who had offered 
their secret freely to American doctors the year before. 

But the women chose another way: they drove their 
doctors to the University of Baden Frauenklinik, scien- 
tific America went to Freiburg in a great migration. At 
one time there were fifty doctors registered in the big 
hotels and the persons and numbers changed all the time, 
so it is impossible to say what the total was. When the 
war came in August, a score were left behind. They were 
among the most efficient people on the committees who led 
their compatriots to the coast. 

When we left a month later the Frauenklinik staff were 
at the war. There were no doctors at the hospital save 
two younger interns and one American who had been ad- 
mitted earlier to follow other work but who now offered 
himself and was accepted as a substitute in the obstetrical 
division. The Bed Cross ambulance flag was run up, the 
whole private ward floor was given over to wounded men, 



120 AUTHENTIC TWILIGHT SLEEP 

and Dammerschlaf was confined to the birth-rooms and 
the general ward. 

Those of us who saw the doctors go, and the hospital 
transformed into a lazaretto, felt as if our effort to give 
publicity to the Dammerschlaf work had been guided to 
an almost providential timeliness, and that for months if 
not years to come, the women of America who had been 
broad-minded enough to respond to our message, with a 
prompt enthusiasm of response that has never been 
equalled, must be the custodians of the great gift to wom- 
anhood that for all time must be remembered as Kro- 
nig's and Gauss's contribution to the humanisation of 
obstetrics. 

In the early fall the American doctors had all gathered 
in America again and the serious work for Dammerschlaf 
began. There is probably no local or national medical 
body in America which has not had a session or many 
sessions on Dammerschlaf. The records of these sessions 
will not be published for many months, but we know that 
in only one city did the body of medical men officially dis- 
approve the agitation for Twilight Sleep. This was the 
Medical Society of Milwaukee County, which condemned 
the whole idea in a sweeping resolution without discussion. 

The women of Milwaukee were not asleep when this 
happened. Three days later the "Women's Association of 
the Milwaukee Maternity Hospital put themselves on rec- 
ord in an emphatic resolution condemning the action of 
the Medical Society. 

In most bodies the root-and-branch opposition was no- 
ticeable as being made by a few men who prefaced their 
remarks with the statement that they had personally had 



TIME HAS TOLD : FREIBURG TO NEW YOEK 121 

no experience with Dammerschlaf. For the rest, the 
meetings were mainly for information, not opposition, and 
brought ont that broad and simple attitude of mind in 
which the medical profession, now that the first shock and 
indignation was passed, was approaching the Dammer- 
schlaf. In most cases the discussions were prolonged and 
adjourned unfinished, to be taken up a week or so later. 

We find clippings of meetings at Philadelphia, Chicago, 
Boston, St. Paul, St. Louis (the latter representing the 
medical associations of three States) , Cincinnati, Milwau- 
kee, Jersey City, Cleveland, Richmond, and many other 
places, and of lectures in still others. They give an idea 
of the wide geographical distribution of intensive work 
with Dammerschlaf on the part of physicians. 

New York gives an idea of how many more sessions 
have been held than are reported in the newspapers. Only 
two medical meetings on this subject were reported. Yet 
during the last three months probably a dozen meetings 
have been held. The conference of the American Asso- 
ciation for the Prevention of Infant Mortality discussed 
the subject. The Public Health Division of the American 
Academy of Medicine addressed a memorandum on it to 
the obstetrical division of the Academy which had dis- 
cussed it at three of its monthly meetings. This memo- 
randum is peculiarly important in the history of medicine 
as well as in the history of women. For the first time a 
national medical body has put itself on record as demand- 
ing what individual obstetricians of sensitiveness and sym- 
pathy have been demanding for two generations ; what all 
women should have been having since the use of anaes- 
thetics. It urges medical men to take the consideration of 



122 AUTHENTIC TWILIGHT SLEEP 

Dammerschlaf into its own hands, not leave it in the pub- 
lic press, for if not by this means then by some other "the 
pains of maternity should be abolished." 

This is the underlying theme of all these meetings. 
The women of America have made the relief of birth pain 
an issue. They believe that the Dammerschlaf is so far 
the most efficient and the safest method. Their belief is 
echoed by a doctor at the Woman's Division of the Acad- 
emy of Medicine. She stated that the Freiburg Dammer- 
schlaf could with infinite pains to doctor and nurse be 
administered safely and successfully to women in labour, 
and that the "decision as to whether it should be used lay 
not with the doctor but with the women themselves." 

Many and divergent are the personal views brought out 
at these meetings. Though these are not as important as 
the personal experiences with scopolamin-morphin, it is 
interesting to learn that a Long Island City doctor was in 
Europe last summer but did not stop at Freiburg because 
"his mother and others of her day managed to get along 
without painless methods, and childbirth is no joy-ride 
under any circumstances." Another New York doctor 
considers the subject indelicate and almost advises a censor 
to keep such matters out of the public press. Over against 
the stupid brutality of such men as this it is gratifying to 
hear Dr. Henry Schwartz, of St. Louis, go out of his way 
in speaking on prenatal care to say that Twilight Sleep has 
called attention to the fact that "in spite of all modern 
advances, a large proportion of women do not receive the 
protection against pain to which they are surely entitled." 
He recognises relief from the burden of apprehension as 
an essential part of prenatal care. 



TIME HAS TOLD : EKEIBUKG TO NEW YOEK 123 

The range of approval on the basis of small experience 
with Dammerschlaf that ran in the meetings was wide. 
Dr. Cragin, of New York, who was observing chosen cases 
under Twilight in Sloane Maternity, was one of those who 
believes that it will be years before enough statistics are 
collected in America to form a definite judgment of the 
value of the method. Dr. J. Thompson Schell, of Phila- 
delphia, declared unqualifiedly without awaiting the pas- 
sage of years since Ereiburg has had and recorded its ten 
years' experience that Twilight Sleep "is a distinct step in 
advance in medical science and deserves the support of 
obstetricians everywhere." 

Those who reported large or small experience fell into 
three groups: out from cover came some physicians who 
at the time of the reckless experimentation of a few years 
ago had been of the cautious few spoken of before and who 
had continued their use, since they had had no accidents. 
Some of these had used the unstable and unsatisfactory 
hyoscin instead of scopolamin, and a fuller report on their 
experience would be necessary to judge of its value. Some 
of these are now stating that since they have learned the 
Freiburg technique and used the stable scopolamin their 
results have been wonderfully improved. Stable scopol- 
amin, by the way, does not have to be imported from Ger- 
many, as Dr. W. H. W. Knipe has shown that Straub's 
Scopolamin haltbar can be prepared by a responsible drug- 
gist, from Professor Straub's published formula. 

One of those whose use of scopolamin goes back to long 
before the Dammerschlaf agitation is Dr. Bertha van 
Hoosen of the Mary Thompson Hospital in Chicago. She 
has had many hundreds of cases, has had no accidents, no 



124: AUTHENTIC TWILIGHT SLEEP 

babies with breathing difficulties. She uses the Freiburg 
requirements in environment and regulation of dosage, 
but her dose of scopolamin is larger and her morphin is 
cut down to even smaller proportions than at Freiburg. 

Among the older users of scopolamin-morphin in obstet- 
rics was Dr. F. S. Newell, of Harvard, whose sensitive- 
ness to pain in childbirth is illustrated by his reputed say- 
ing that it is almost better to deliver a sensitive woman by 
csesarean section than to let her suffer the long agony of 
parturition with its subsequent breakdown. He is in a 
class by himself. He has used scopomorphin so skilfully 
in about 250 cases that he had little to learn from Frei- 
burg. He does not believe, like Freiburg, that it can be 
used with all patients. He believes, that is, that there are 
some contraindications in the individual patient's physi- 
cal condition. In this opinion his standing gives him some 
weight, though his experience is only one-twentieth that of 
Freiburg. His requirements in giving the sleep are like 
those of Freiburg, a hospital environment, a stable drug, 
and an intern administering, of a high degree of obstetric 
skill and responsibility. 



CHAPTEE VIII 

Time Has Told: American Eepoets on Authentic 
Twilight Sleep 

At the September, 1914, meeting of the American As- 
sociation of Obstetricians and Gynecologists were read 
the first two reports on adequate series of cases under 
Dammerschlaf. There were Harrar and McPherson's 
report on 100 cases in the Lying-in Hospital in New York 
and Eongy and Arluch's report on about the same number 
at the Jewish Maternity Hospital in the same city. 

At subsequent State and local meetings the work of 
many other hospitals has been reported on, verbally or 
formally, in Chicago, Cleveland, Washington, St. Paul, 
and many other cities. In JSTew York there are a dozen 
hospitals. Probably there is no city of any importance 
east or west, north or south, which is not "trying the Twi- 
light." Thus we hear that Dr. Wakefield is using it in 
his private hospital in San Francisco, that indeed he was 
using it long before the popular agitation began. In Bos- 
ton the Massachusetts Homoeopathic Hospital is said to be 
approaching its hundredth case. 

On all these hospital experiences we can pass no judg- 
ment until their reports are published, for we do not know 
what method they are using. 

There are at present in America two methods that go 

125 



126 AUTHENTIC TWILIGHT SLEEP 

under the name of Twilight Sleep : the true Gauss's Dam- 
merschlaf, and a method referred to by American doctors 
as Siegel's method. 

Both these methods are at present being used in Frei- 
burg Frauenklinik and have occasioned much confusion to 
the doctors visiting there. 

Siegel's method is an experiment in fixed dosage which 
had been going on for about a year when the war broke 
out. It was started with a view to finding whether or not 
it was possible to work out a fixed dosage by which all 
women could be treated and the doctor saved the delicate 
adjustment which Gauss's Dammerschlaf requires. It 
makes no study of the individual patient ; it uses no mem- 
ory test, supplies no carefully adapted environment, and 
is carried on simply by use of a hypodermic needle every 
hour and a half. Dr. Gauss hit its value off when he said 
of the method : "If you could trust to having an average 
woman, you could use an average dose; but the dose is 
easier to standardise than the woman." In practice, 
Siegel's fixed dosage tends to overdose both mother and 
child and makes the latter too deeply apnoeic, even asphyx- 
iated. For that reason, Freiburg Frauenklinik uses nar- 
kophin, a more harmless preparation than morphin in 
Siegel's cases. In the delicate adjustment required by 
the real Dammerschlaf Gauss prefers minute doses of 
morphin. 

Siegel's method has been used on only a few hundred 
cases, and is in every sense merely an experiment, not an 
approved method, at Freiburg. 

Gauss's Dammerschlaf, with its delicate adjustment of 
the amount to the individual, its memory test, and other 



TIME HAS TOLD : AMEBICAN BEPOBTS 127 

means of guiding every moment of the sleep, its special 
environment and all the elements that make it safe and 
successful, is the method used in all but one ward of the 
Freiburg Frauenklinik. 

This is the only method that is safe to introduce into 
America. 

But Siegel's ward is the free ward of the Frauenklinik, 
and this is the ward to which doctors who made only a 
few days' stay in Freiburg had readiest access. The only 
literature these doctors carried away from Freiburg was 
Siegel's short report on two hundred odd cases, not Gauss's 
series of reports on 3,600 cases in true Dammerschlaf. 

The experienced obstetrician seeing Siegel's cases, dis- 
approved of the method heartily. It is under a miscon- 
ception that Siegel's is the true Dammerschlaf that Dr. 
Joseph B. de Lee, of Chicago University, has recently 
criticised the Dammerschlaf. As he expresses in that very 
criticism an open-minded willingness to learn, there will 
be plenty to call the technique of Gauss's Dammerschlaf 
to his attention for the new hospital wing where he offers 
to try it. 

Younger physicians of less observation, experience, and 
judgment than Dr. de Lee came home from Freiburg with 
Siegel's monograph in their pockets and have been ap- 
plying his dosage schema automatically to their patients. 
This schema is the greatest menace to scopolamin-morphin 
in America to-day. As long as it figures as "Freiburg 
Dammerschlaf" any accident, great or small, which comes 
from its overdosing threatens the popularity of the real 
method. 

Physicians who claim that Professor Kronig recom- 



128 AUTHENTIC TWILIGHT SLEEP 

mended the Siegel method in his speech at Chicago in the 
fall of 1913 must rememher that he said it worked all 
right in what he called a normal case — the "average dose 
for the average woman" — and that he recommended that 
Siegel's schema be used merely as a starting point, the 
average being varied to suit the individual. Many physi- 
cians will remember as an incident of that meeting that 
Professor Gauss, though Kronig was his superior, would 
not allow him to give out Siegel's schema, knowing that 
the tendency would be to apply it automatically. 

Siegel's schema applies a certain fixed dose every hour 
and a half, and this may in some women tend to slow 
labour, in some cases prolonging it a great deal. A real 
case in true Dammerschlaf will illustrate. A woman was 
given her first injection when the pains were -Q.Ye minutes 
apart; and three quarters of an hour later — about the 
usual distance apart for first and second doses — a second 
injection. Labour slowed down and pains came far apart. 
The intern, instead of giving the next dose one and a half 
hours after, as fitted in most of the cases he had had, called 
up the obstetrician, who extended the interval to three 
hours, when an average dose was given. By that time the 
pains were nearer together. But he would take no risks, 
and after an hour and a half gave only half the customary 
dose. After that labour proceeded normally. For rea- 
sons not relevant in this connection but connected with the 
condition of painlessness, it proved to be a particularly 
"beautiful case." It illustrates the importance both of 
adaptation to the individual and of a high degree of skill 
and judgment in the administrator. 

Siegel's method is discountenanced by all doctors who 



TIME HAS TOLD : AMERICAN REPORTS 129 

stayed at Freiburg long enough to learn the real Dam- 
merschlaf . Their chief fight is against it, as it furnishes 
just the easy means of using scopolamin-morphin without 
skill or judgment which an ill-equipped general practi- 
tioner would seize upon and work damage with. 

As far as we can conjecture, we may by this time in 
America have equalled or surpassed Gauss's classic num- 
ber of 3,600 cases under his true technique. 

Four large New York hospitals using Gauss's Dammer- 
schlaf have published reports on a series of cases. 

The work done in these hospitals has been excellent in 
proportion to the standard of the obstetrical work of the 
hospital. 

The reports are all the more creditable considering the 
fact that none of the men administering Dammerschlaf 
are Freiburg-trained in that particular. 

This is a fact that would shock the rigid requirements 
of the Frauenklinik which will turn no man out as 
equipped if he has not had his two years' training in the 
application of all his obstetrical knowledge to the specific 
work of conducting Dammerschlaf. 

Nevertheless, granting this handicap, these New York 
hospitals have the literature of Dammerschlaf, the de- 
tailed published study of the technique to build upon, and, 
considering their handicap, they have done well on this 
basis. 

Of the two hospitals reporting at Buffalo, the work in 
the Jewish Maternity was conducted by Dr. Schlossinck, 
who had been an intern at Freiburg and had observed sev- 
eral Dammerschlaf cases there, though this had not been 
his work. He came forward to answer the outcry of fraud 



130 AUTHENTIC TWILIGHT SLEEP 

made against the Freiburg Erauenklinik in consequence 
of "sensational" magazine articles. He wished to prove 
that the Ereiburg method was a legitimate medical pro- 
cedure. 

He worked quietly through the summer, and in the fall 
Drs. Eongy and Arluch of the Jewish Maternity were 
able to report about 100 cases. 

As far as possible in a noisy East-Side street, quiet was 
obtained in the confinement room where these cases were 
delivered with darkness and as little coming and going in 
the room as possible. The memory test was used to regu- 
late the dose. 

Nine per cent, of the cases were unsuccessful in respect 
to the relief of pain. In four cases labour appeared to be 
lengthened in the second stage. About twenty per cent, of 
the babies had oligopnoea, or light breathing, but estab- 
lished regular breathing in almost all cases of themselves 
without stimulation of any sort. 

On the basis of this experience Rongy and Arluch came 
to the following conclusions : 

"Standard solutions are absolutely essential for the suc- 
cess of this treatment. 

"No routine method of treatment should be adopted. 
Each patient should be individualised. 

"Facilities should be such that the patient is not un- 
duly disturbed. 

"A nurse or physician must be in constant attendance. 

"This form of treatment is carried out in hospitals, al- 
though there is no reason why it cannot be accomplished 
in all well-regulated private houses. 



TIME HAS TOLD : AMEEICAN REPOKTS 131 

"It does not affect the first stage of labour, but the sec- 
ond stage is somewhat prolonged. 

"Pain is markedly diminished in all cases, while am- 
nesia (loss of memory) is present in the greatest number 
of patients. 

"This treatment does not in any way interfere with any 
other therapeutic measures which may be deemed neces- 
sary for the termination of labour. 

"To condemn or advocate a given therapeutic measure 
without a thorough personal investigation is truly un- 
scientific and not in accordance with the tenets of pro- 
gressive American medicine. 

"Judging from our observations and experience, we 
feel that this method of treatment should be given a fair 
trial. It is only the varied experience of competent men 
that will tend to settle this extremely interesting subject. 
It is the duty of the medical profession to set the public 
aright on this very important question. Eor our part, 
we believe that this mode of treatment relieves the woman 
of the agonies of labour and in addition instils a feeling 
of confidence which materially aids her in passing through 
the trying ordeal." 

A subsequent fifty cases confirmed the conclusions from 
the first series and the Jewish Maternity has installed 
the Twilight as a regular procedure. 

We have quoted Harrar and McPherson's reason for 
undertaking their investigations. Their report covers 100 
cases in the Lying-in Hospital in New York. 

They go further than the Jewish Maternity report. 
Since they have had personal experience with the old 
method of using scopolamin-morphin they can compare 



132 AUTHENTIC TWILIGHT SLEEP 

it with the new. Of the old use they say: "The crux of 
the proposition seemed to lie in three errors: Eirst, most 
men in this country, at least, used a combination of the 
two drugs, scopolamin and morphin, not only for the ini- 
tial dose, but for the succeeding doses as well ; second, the 
bad results were due also to excessive dosage, and to the 
use of unstable and deteriorated preparations of scopola- 
min; and third, the erroneous notion prevailed that the 
method was to abolish the sufferings of labour, whereas it 
is intended only to prevent memory of the event." 

In Kronig's Chicago address he dwells on the appear- 
ance of suffering that sometimes occurs during a Twilight 
Sleep, and states as one of his reasons for keeping the 
family out of the room that they, not being scientifically 
fortified as to the particular condition of consciousness, 
will not believe that the patient is not in pain. More 
than one doctor in America has recently been cheated in 
the same way. A story is told of one Twilight Sleep 
mother who abused her doctor all through and begged for 
relief. She finally settled down in resigned despair with 
a parting shot: "If this is your Twilight, I don't think 
much of it, and I'll tell my friends what I think." By 
this time the doctor began to believe her and resolved that 
this should be his last Twilight case. Some hours later, 
after the baby's birth, the doctor was astonished to hear 
her express the hope that labour would come on soon. She 
could not be persuaded that her baby was born. 

Drs. Harrar and McPherson record such experiences, 
and dwell upon the "interruption of mental associations" 
or abolition of memory and not complete painlessness as 
the criterion for the desired condition. This mental con- 



TIME HAS TOLD : AMERICAN EEPORTS 133 

dition is checked by the memory test, which is not capable 
of routine application. "It requires/' says the report, 
"the nicest judgment to suit the test to the standard of the 
intelligence of a given case, especially in patients of the 
lower grades of mentality." This is repeating the words 
of Freiburg in regard to the delicacy of applying the mem- 
ory test. 

They note also that since the obstetrician cannot rely 
on pain as a full guide of the progress of labour, he must 
observe the uterine contractions by touch. Under Twi- 
light, Drs. Harrar and McPherson constantly watched the 
child's and mother's heart and kept written records of 
conditions. That the mother 'and child have heretofore 
been left to themselves in their labour and that this is 
the first time in the history of medicine that labour has 
been scientifically followed and recorded, comes as a sur- 
prise to some of us. It bears out the statement of some of 
the doctors that their Twilight cases are teaching them 
obstetrics. They never troubled much about the child's 
breathing condition at birth before, nor watched in normal 
cases the foetal heart. Observation of Twilight cases 
makes it appear highly probable that some cases of stran- 
gulation by the cord could have been delivered quickly and 
saved if the heart had formerly always been watched dur- 
ing labour. 

These are not, however, the observations and reflections 
of the Lying-in report. Drs. Harrar and McPherson 
simply lay down their requirements and procedure and go 
on to their results in their 100 cases under scopolamin- 
morphin. 

Sixty-five per cent, had complete painlessness, or am- 



134 AUTHENTIC TWILIGHT SLEEP 

nesia. Twenty-five per cent, had partial relief. Of the 
rest, some were of the class known as refractory to nar- 
cotisation, the most part got their first injection too late 
in labour to have any effect. 

Harrar and McPherson treated these cases side by side 
with a hundred births in consciousness, and made some 
interesting parallel observations. 

They found two severe haemorrhages and thirteen slight 
ones in their hundred cases without scopolamin-morphin; 
two fairly severe and eight slight haemorrhages with sco- 
polamin-morphin. In these cases and in general, the Twi- 
light cases showed less blood loss. 

The average duration of labour in the Twilight cases 
was two hours shorter than in those without. They be- 
lieve shortening was in the first stage of labour; the sec- 
ond was somewhat lengthened. At first this lengthening 
alarmed them so that in the early cases they used the for- 
ceps rather more frequently than in the cases without 
scopolamin-morphin. Later they learned better. There 
was less laceration in the Twilight than in the other cases. 

The testimony for the child in the series of births fol- 
lows: 

"As to the occurrence of foetal asphyxia, in the hundred 
delivered without scopolamin, there were seven instances 
of asphyxia at birth, two of them requiring tubes and arti- 
ficial respiration for twenty minutes. In the scopolamin 
babies the majority cried at once without any evidence of 
being under the influence of a drug, eight were moder- 
ately apnoeic, but responded promptly to flagellation and 
tubes, and two required artificial respiration for fifteen 
and twenty minutes. The asphyxia that occurred was in 



TIME HAS TOLD : AMEKICAN EEPOETS 135 

those cases where there was delay of the head on the peri- 
neum. Under the old technique the frequent severe foetal 
asphyxia was due to the repeated doses of morphin." In 
this series asphyxia, the only dangerous breathing impedi- 
ment at birth, occurred more frequently in the cases with- 
out than in those with scopolamin. This bears out Gauss's 
observation that this serious breathing difficulty is not 
caused by scopolamin-morphin. 

It will be observed that in these cases Harrar and Mc- 
Pherson comment on the fresh and vigorous condition 
of the mother after birth and her rapid recovery. 

For best results, say Drs. Harrar and McPherson, "all 
the details of the Krbnig and Gauss technique should be 
followed methodically." 

The two remaining reports are particularly interesting 
as showing how important is long experience to Twilight 
Sleep. To the obstetrician equipped with both insight and 
training, painlessness counts for much in the birth process. 

Drs. W. H. W. Knipe and J. O. Polak reported in 
October two groups of cases: the one in Gouverneur and 
the other in Long Island College Hospital. To-day these 
two hospitals must have between them at least 300 cases. 

These two men are among those who went to Freiburg 
in the summer of 1914; they are also both among those 
who had tried and failed with scopolamin-morphin in the 
past and had discarded it as dangerous. 

They both ascribe their early failure to ignorance of 
the Freiburg technique, and Polak expresses the emphatic 
belief that the women and babies in the experimental days 
in America were morphinised. He believes that the cut- 
ting down to the minimum of morphin is one great ele- 



136 AUTHENTIC TWILIGHT SLEEP 

ment in the superior safety of the Freiburg method. Of 
the experience of Ereiburg he says in general : 

"They have recently published a report of 4,111 cases 
of labour in which narkophen or morphin and scopolamin 
have been used, with a lower foetal and maternal mortality 
than has been secured in any other clinic in Europe. These 
results have been attained, first, by individualising the 
patient; second, by limiting the number of vaginal ex- 
aminations, and giving each woman a full test of labour, 
without reducing her physical strength by subjecting her 
to nerve-racking pain." 

His general account of the full significance of painless 
labour to the birth process is so interesting as well as 
authoritative that we must quote in full: 

"We contend a woman is entitled to the relief of pain 
during labour, if she can get it, without undue risk either 
to herself or to the unborn child. We no longer ask our 
patients to submit to surgical operations without ether or 
gas; many of us use ether or chloroform as a routine 
during the perineal stage in ordinary labour; we likewise 
narcotise the woman for a forceps delivery or primary 
repair of the pelvic soft parts. Why not extend this com- 
fort throughout labour by producing amnesia and anal- 
gesia with safe doses of scopolamin, which does not, if 
judiciously used, affect uterine contractions when they 
are once established ? 

"You say labour is a normal and physiological process ; 
one wouldn't think so after twenty-odd years of consulta- 
tion obstetrics in Brooklyn and New York. Over fifty 
per cent, of all of our gynaecology is the result of badly 



TIME HAS TOLD : AMERICAN REPORTS 137 

conducted physiological labour. Poor diagnosis in labour 
is more frequent than in any department of medicine and 
surgery, except perhaps in cancer. The practitioner has 
not made the progress in the art of obstetric diagnosis and 
procedure that he has in other branches, or he is blinded 
by the dictum that it is all a normal process. 

"Many of us seem to forget that the cervix must be open 
before the child can pass through it ; others delude them- 
selves into the idea that they can artificially dilate the soft 
parts as perfectly as with nature's processes, and few of 
us give nature sufficient time to prepare the way. Dead 
and mutilated babies, torn and prolapsed organs, with 
resulting morbidity from infection, are some of the causes 
which have produced this public demand for adoption of 
the Freiburg method. 

"We educate the public how to prevent disease ; they are 
going to educate us how to prevent many of the disasters 
of childbirth by insisting on better antepartum and inter- 
partum care. 

"Painless labour by partial narcosis with scopolamin 
and narkophen is an assured fact, and when used in 
properly selected cases, where the foetal and pelvic rela- 
tions are normal or approximately normal, it permits na- 
ture to take time to perfectly prepare the cervix, vagina, 
and vulvar orifice for the passage of the fcetus without 
producing in the woman physical or muscular fatigue. 

"It is easier to dilate the sphincter ani under anaes- 
thesia than with the patient conscious; so it is easier to 
dilate the cervix when the pain of this dilatation is not felt 
by the patient, than when the circular muscle is in spasm ; 



138 AUTHENTIC TWILIGHT SLEEP 

particularly is this so when the dilatation is accomplished 
by those forces intended for this purpose. 

"The advantages, therefore, of painless labour are less 
nervous shock, less muscular effort, and easier and more 
prompt cervical dilatation. Our observation proves that 
scopolamin and narkophen actually shorten the first stage 
of a primiparous labour by more promptly overcoming the 
soft parts' obstruction. This is not so of the second stage, 
which may be prolonged beyond safe limits if the attend- 
ant is not keeping close watch of his patient. 

"Scopolamin-narkophen anaesthesia is not without dan- 
ger; neither is the production of narcosis with ether free 
from accident or complication ; yet, in proper hands, these 
dangers can be and are minimised. 

"The mother may be particularly susceptible to scopol- 
amin or morphin, the former causing delirium, the latter 
coma; or the respiration may become arhythmic, and re- 
duced to five or six per minute. The kidney secretion 
may be diminished or anuria develop ; labour may be pro- 
longed, especially in the second stage. Uterine atony is 
possible, and postpartum haemorrhage has been charged to 
the method by some American observers. 

"In our clinic we have found that all of the above- 
mentioned dangers are exaggerated and are due to too 
much morphin and can be anticipated and prevented by 
intelligent administration, by the use of the minimum dose 
to produce sleep, the individualisation of the patient, and 
the very free exhibition of water throughout the narcosis. 

"It has been claimed, by the critics of this method, that 
the child is apt to be asphyxiated and narcotised; this 
again is not the fault of the method, but of the dosage. 



TIME HAS TOLD : AMEKICAN EEPOETS 139 

The child does participate to some extent in the Twilight 
Sleep. Many of the children suffer from oligopnea for 
several minutes, and it is common for the child not to cry 
for two or three minutes after birth, though the foetal 
heart may show little or no disturbance in rate of rhythm ; 
there is, however, no cyanosis unless the dosage of morphin 
has been too large or given at too frequent intervals, or 
the second stage has been allowed to continue too long. 

"The child after stretching itself, as if awakening from 
a restful and peaceful sleep, cries as lustily as the ordi- 
nary newborn infant. As the patient may be wholly un- 
aware of the progress of labour, even during the perineal 
stage, it is not uncommon for the foetus to be delivered 
unannounced, as the change in the character of the wom- 
an's pains may not be noted by the attendant, unless the 
vulva is exposed. It is possible, therefore, for the foetus to 
drown in the gush of amniotic fluid, should such an acci- 
dent go unobserved. 

"From our observations both here and abroad, we are 
convinced that there is no reason why Dammerschlaf 
should not be given to all women who show the physical 
signs of active labour, provided that the woman is under 
continuous and intelligent observation. 

"It is particularly indicated in nervous women, of the 
physically unfit type, in their first labour, for it is in this 
type of women that labour has most often, in ordinary 
practice, to be terminated artificially, owing to the physi- 
cal exhaustion so common at the end of the first stage, 
before cervical dilatation is complete, or in the second 
stage, when no more force can be brought upon the uterus 
by the abdominal muscles. The usual obstetrical interfer- 



140 AUTHENTIC TWILIGHT SLEEP 

ence by forceps in the presence of unprepared soft parts 
results in a permanent morbidity, and it is the largest con- 
tributor to our collection of chronic invalids. 

"It is just in this class, the physically unfit, that scopol- 
amin will give the best results, for by its use we are able 
to attain full dilatation of the cervix by the physiological 
factors — i.e., the bag of waters and the force of the uterine 
contractions — before the patient begins to show signs of 
physical tire. In dry labours, the exquisite pain which is 
produced by the pressure of the presenting part on the 
sensitive congested cervix is relieved and the cervical ring 
relaxed. The presenting part is therefore driven through 
the pelvis and well into the vagina, and low forceps in a 
dilated passage is the most serious intervention to which 
the woman is subjected. Operative traumatism is thus 
reduced to a minimum. Surely scopolamin would he 
worthy of a place in midwifery, were it only to secure for 
us, as it does, full dilatation of the cervix. 

"All of us of any obstetric experience have noted the 
effect of a full dose of morphin near the end of the first 
stage, in dry labour, and have seen the cervical ring ac- 
tually melt away under its influence ; this is accomplished 
by allaying restlessness, allowing the woman rest and sleep 
between the pains, diminishing the cervical sensitiveness 
and relaxing the cervical spasm. Scopolamin-narkophen 
analgesia does all this, and in addition permits the labour 
to proceed without the patient having further knowledge 
or memory of subjective pain. 

"There can be no doubt that dry labours, due to early 
rupture of the membranes, will afford an excellent field 
for Twilight Sleep. Borderline contractions will offer 



TIME HAS TOLD : AMEEICAN EEPORTS 141 

another indication for its trial, for all primiparse with 
borderline contractions must be given a test of labour be- 
fore instituting operative measures : This means that the 
cervix must be dilated, the membranes ruptured, and that 
the uterine contraction, aided by proper posture, be given 
a chance to drive the presenting part into the pelvis. This 
all takes time and effective labour pain. These patients 
are in need of rest, because having labour pain is work, 
and work exhausts. Under combined analgesia the woman 
may be carried for hours without showing any of the 
classical signs of exhaustion, in the character of the pulse 
or in the character of the labour pains, and if operative 
delivery is indicated in the interest of the mother or child, 
it may be accomplished with less general anaesthesia." 

Polak alone among doctors using scopolamin-morphin 
or scopolamin-narkophen in general fearlessly applies 
Gauss's rule of using it in all cases ; he recognises, that is, 
no "contraindications." In the cases reported at the Long 
Island College Hospital there have been no failures in 
respect to painlessness. There has been occasional slowing 
of the second stage of labour, but there has been no injury 
to the birth process. Instead, there have been those im- 
provements in the normal process which his general state- 
ment just quoted brings out. Only two children showed 
temporarily impeded breathing and, of these, one case was 
due to other causes than the narcotic. 

In Dr. Knipe's series at Gouverneur there was a small 
percentage of oligopnoeic babies, but all but three of these 
had the cord wound twice around the neck. These three 
soon got their breath. He believes that any marked de- 



142 AUTHENTIC TWILIGHT SLEEP 

gree of oligopnoea is due to an overstepping of the Twi- 
light zone and with proper dosage oligopnoea is unneces- 
sary. This overstepping he holds is due to the cumulative 
effect of doses too near together. Skilful use of the mem- 
ory test he believes obviates this, as by following this 
means of regulation one dose is used up, so to speak, before 
another is given and no surplus accumulates. Though 
oligopnoea unless very deep is not a dangerous condition, 
he believes that it should be avoided. 

Cumulative overdosing, or overdosing at the beginning 
of labour — "forcing" the Sleep which Gauss strongly 
argues against, instead of inducing it gradually — Dr. 
Knipe believes is responsible for any serious slowing of 
the mother's labour that has been observed and other dis- 
agreeable effects sometimes encountered from scopolamin- 
morphin. 

In general he believes that under properly conducted 
Twilight Sleep there may be some slight slowing of labour, 
possibly a half hour to an hour, but no alarming retarda- 
tion. 

In the Gouverneur series of cases seventy-eight per cent, 
of the mothers had complete amnesia, only ten per cent, 
were completly uninfluenced by the narcotic. 

Dr. Knipe expresses enthusiasm for the remarkably 
quick recovery of his mothers, and he recommends the 
active convalescence and the muscular exercises customary 
at Ereiburg, which he believes restore the organs to their 
position and their strength more quickly than the usual 
mode of convalescence from childbirth. He and Dr. Polak 
are alone among American doctors in recommending active 
convalescence, but his arguments are strong, and the 




Gouverneur Hospital in New York, where Mrs. Haxs Leuderman's 
Baby was born in January, 1914, has reported success in over 100 cases 
of Twilight Sleep, and is the only American clinic which employs the 
"active convalescence" of Freiburg. 



TIME HAS TOLD : AMERICAN REPORTS 143 

method works excellently at Freiburg. The form of con- 
valescence has, of course, nothing to do with Twilight 
Sleep, except that such activities would be quite impossible 
for a mother convalescing from the traumatic shock of a 
painful birth. 

All the doctors comment on the mothers' eagerness to 
get up after a painless birth, although some will not allow 
them to. 

In their successes both Polak and Knipe followed 
rigidly all the rules of Gauss's Dammerschlaf procedure. 
They believe, like Kronig, Gauss, and Newell, that for 
success and safety scopolamin-morphin-seminarcosis de- 
mands the hospital and the attendance of a skilled and 
responsible obstetrician. 

"Twilight Sleep," says Dr. Knipe, in the Medical Rec- 
ord, "undeniably demands more care, more thought, and 
more knowledge than a normally conducted labour. This 
increased attention paid to childbirth must result in better 
obstetrics by the general practitioner. This in turn will 
increase the respect of the public for obstetrical care and 
obstetrics in general will be held in higher esteem by phy- 
sicians themselves. As a result of all this, there will be 
fewer stillborn children, fewer mothers sacrificed, and 
the number of invalids following neglected labour will 
diminish markedly. 

"Inasmuch as most obstetrical cases must be attended 
by the general practitioner — and then frequently in com- 
munities where no hospital exists — it will become neces- 
sary to establish local hospitals where the physician may 
send his patient to have the Twilight method administered 
by a nurse or physician trained in this method. When 



144 AUTHENTIC TWILIGHT SLEEP 

the time of delivery approaches the physician may be 
notified so that he may deliver the child in the hospital. 
This seems to me the practical solution of the problem of 
how the large mass of the population is to receive the 
benefit of Twilight Sleep, for, of course, it becomes impos- 
sible for a man with an active general practice to give the 
uninterrupted attention to his obstetric cases that the 
Twilight method demands; and unless continued observa- 
tion of the patient in Twilight Sleep is carried out by 
some one accustomed to the technique it is better not to 
attempt the method at all." 

This open hospital should come soon to facilitate the 
demonstration and the widespread dissemination of the 
knowledge of Dammerschlaf technique; for while the 
work is being carried on successfully in the hospitals not 
originally equipped for it, its added burden is carried by 
medical and nursing staffs which have not been increased 
as at Freiburg, although hospitals where Twilight Sleep 
is known to be administered are receiving more than twice 
their previous rate of maternity cases. 

Dammerschlaf, at the moment that war threatened its 
continuance at Ereiburg, was transferred to America and 
rechristened the Twilight Sleep. Eour or five million 
women came to its christening. These sponsors will be 
kept informed of its development; most of all, they will 
be kept informed when and how it is threatened. 

Twilight Sleep is to-day threatened in three ways : 

(1) By haphazard use by the general practitioner. 

(2) By the spreading of the Siegel method of fixed 
dosage. 

(3) By the inhibitive influence of that group of ob- 



TIME HAS TOLD : AMEKICAJST EEPOETS 145 

stetricians who urge putting off a decision as to its value 
for two or three years. 

When the two women who had made a pilgrimage to 
Freiburg returned to New York and found the widespread 
enthusiasm and the demand to learn more, they decided 
to appear in the open market-place. They could have 
spoken, they did indeed often speak, before intellectual 
audiences under very respectable auspices; but the ordi- 
nary woman who does not belong to clubs was begging to 
hear. 

They believed that it was not the conventionality of 
the place they spoke in, but what they said that mattered. 
So they spoke where the mother of the family does her 
household buying, in the department store. They were 
advertised between the marked-down suits and the table 
linen. 

One of these Freiburg women brought her baby to show 
that he was neither retarded in his physical growth nor 
developing into an idiot. 

They brought also the woman who had packed her 
trunk and hurried to Freiburg when she read the first 
"sensational" article on Twilight Sleep. She brought her 
three months' baby. She was a woman in private life, 
but the occasion raised her above the shyness of the 
woman in private life. She delivered her message from 
her own experience as spontaneously and with as little 
consciousness of self as though she were not personally 
involved. 

She was only surpassed by the tenement-house mother 
who, with her new Twilight baby in her arms, stopped on 
a street corner to tell a friend of her experience. The 



146 AUTHENTIC TWILIGHT SLEEP . 

magic word Twilight Sleep collected a crowd. She lifted 
up her baby, then, for all to see, crying impulsively: 
"This baby was born in Hospital a week ago with- 
out pain!" 

The response is as spontaneous as the appeal. The 
women are hearing a matter of life and death to them. 
They are contemptuous of those medical reviews which 
suggest an injunction against the speakers, or express 
shame that women can themselves "do violence to those 
reserves and delicacies which usually surround the lying- 
in chamber." 

To the women listeners this squeamish delicacy of the 
male obstetrician seems an outrage. A tragic emergency 
raises the sufferer above the conventions. Childbirth has 
for every woman through all time been potentially her 
great emergency. Nothing could prove this better than 
the testimony of personal experience offered at such meet- 
ings. 

And nothing could prove better the women's grasp of 
what is offered to them than their eager acceptance of the 
hospital in place of the traditional home confinement. 

At one meeting thousands of dollars were offered in 
small sums and with a confidence in the unknown speaker 
that was pathetic. 

The women, like the doctors, want the Twilight Sleep 
only under those conditions of hospital care and the best 
obstetrics, laid down by Freiburg, and designed to insure 
the safety of mother and child. 



CHAPTER IX 
A Dozen Anesthetics and the Forceps 

When the demand of the mother's fear and pain became 
too poignant to refuse relief, or when pain threatened to 
work havoc with the normal birth process, obstetricians 
have had some dozen anaesthetics to give brief alleviation. 

The general practitioner who to-day attends most births 
knows few of these. Chloroform or ether, or the alcohol- 
ether-chloroform combination, are his resources. Even 
these he seldom uses except at the end of a birth. "I have 
never had but one birth that was naturally painless," said 
one country doctor, a but I have never used an anaesthetic 
except where operative assistance was necessary." 

This man has used in his practice that cruel power, 
"the doctor's discretion," which women are attacking since 
the possibilities of painlessness by Twilight Sleep have 
been known to them. They took their doctor's word be- 
fore. They are now beginning to believe, with Dr. Rey- 
nolds of Harvard, that the use of painlessness should be 
at tJieir discretion. 

Whatever the value of his narcotic, one general prac- 
titioner, Dr. M. W. Kapp, shows unusual sensitiveness. 
He writes in the Medical Record of his three years' use of 
heroin in about a hundred confinement cases. 

"The dread and agony of the parturient mothers," says 

147 



148 AUTHENTIC TWILIGHT SLEEP 

Dr. Kapp, "has always worried me. Motherhood is such 
a sacred condition and it should be such a happy condition 
from its first moment through all its stages. With so 
many the dread of the hours of labour depresses them, 
and without any question has its depressing effect on the 
child." 

Most family doctors hurrying on their rounds can walk 
cheerfully out of the room when the screams become too 
distressing, after reassuring the mother that everything is 
going beautifully and, as one said recently, the "best salve 
for her suffering is Spartan courage." 

They have accepted pain as an inevitable accompani- 
ment of labour ; few know that it can even be lessened in 
intensity. Many still believe that labour could not pro- 
gress normally without pain, and very many are still 
guided in watching the course of labour by the mother's 
cries. 

Few general practitioners could have the time or the 
delicate skill to administer any of the obstetrical narcotics 
safely and successfully. 

But the obstetrical specialist is better equipped. He 
has known his dozen anaesthetics. In many cases it is 
true he has dismissed them after short and unconvincing 
experimentation. 

A very common statement by important American ob- 
stetricians at the outset of the Twilight Sleep agitation 
was that physicians knew and used customarily better and 
safer narcotics than scopolamin-morphin to assuage the 
pains of labour. Drs. C. M. Green of Harvard, Whitridge 
Williams of Baltimore, and Joseph B. de Lee of Chicago, 
are quoted by the newspapers to this effect. 



A DOZEN ANAESTHETICS AND FOECEPS 149 

This statement came as a surprise to most child-bearing 
women. Even in regard to obstetrical specialists, it needs 
considerable modification. 

In most cases this assuagement is merely the brief use 
of chloroform at the end. In chosen cases it is that im- 
perfect intermittent use of chloroform a la reine or ether 
throughout the birth merely to blunt the acuteness of the 
pain which is described in another chapter. Two women 
who had this treatment from one of the greatest obstetri- 
cians in America have recently demanded Twilight Sleep 
of him. 

Most of these experts judge for themselves when pain 
relief is necessary throughout the whole course of a birth. 
Many reserve it for a first child ; some even further limit 
it to "primiparse" of advanced age. The Newells and the 
Eeynolds of American obstetrics are rare. The criterion 
of the others is seldom suffering alone, but suffering when 
it becomes a serious impediment to the birth process. A 
half dozen narcotics can be used in the early stages, ending 
the birth with ether. 

Most obstetricians use painlessness at the final delivery, 
and there are chlorethyl, methylen, and a great number of 
other inhalation anaesthetics besides chloroform and ether. 
It is doubtful whether these are superior to the older nar- 
cotics. 

From time to time obstetricians have made small ex- 
periments with different narcotics. A dissertation by a 
German, August Johnen, brings together the experience 
in Europe and America. The demand for Twilight Sleep 
has brought out the use of many more. 

The smallness of the experience on which conclusions 



150 AUTHENTIC TWILIGHT SLEEP 

are based, the contradictoriness of the results by two men 
of equal reputation, and the lack of standardisation are 
the things most striking in the experience with all nar- 
cotics. 

On the basis of haphazard use in eight cases a great ob- 
stetrician gave up one narcotic on the ground that it pro- 
longed labour and caused postpartum haemorrhage. It 
has since come into common use. 

For every obstetrician who makes a favourable report 
on the basis of his inadequate experimentation with half a 
dozen cases, there arises another who reports unfavour- 
ably on the basis of his half dozen. A few have persisted, 
until statistics of success are fairly large. 

The very large but unstandardised experience with 
ether and chloroform has been told in detail. These are 
the only narcotics which, uncombined, have been used in 
a great number of cases over long periods in labour, like 
scopolamin-morphin in Twilight Sleep. 

In England, where their use was first worked out, these 
are the favourite obstetrical anaesthetics. The English 
use is probably more skilful than that of any other coun- 
try. 

In Germany Kronig and Gauss, the enfmts terribles of 
obstetric anaesthesia, have kept scopolamin-morphin be- 
fore the obstetrical public. Those users who have followed 
the standard of Freiburg have had success. This is the 
only obstetrical anaesthetic which has developed a tech- 
nique. 

America has no special narcotic for childbirth, perhaps 
because it is more backward than any other country in 
general anaesthesia. 



A DOZEN ANESTHETICS AND FOKCEPS 151 

The use of cocain originated here. It was used with 
great perfection in combination with scopolamin or with 
hyoscin by the obstetrician Marx in New York. But co- 
cain, stovain, eucain, and novocain have been taken over 
by France. The greatest experience has been with co- 
cain. Dr. Fyffier has had in his clinic the large number 
of thirteen hundred mothers treated hypodermically with 
cocain. Drs. Doleris and Malartic have also had a fairly 
large experience. The total recorded experience is now 
about two thousand cases. 

Cocain is suitable for only the later stage of labour ; it 
is undependable, its effect sometimes wearing off with un- 
expected suddenness, but it almost always gives some re- 
lief. As it is injected directly into the spine, it requires 
great precautions and skill, but no more than the obstetri- 
cian should be able to furnish. 

Hypnosis is another method of painlessness which has 
been developed in France. It is beset with such difficulties 
that it has a very limited application. It is successful 
only when both doctor and patient have the right tempera- 
ment and co-operate with each other in trying to reach the 
hypnotic stage known as somnambulism. If the condition 
passes out of this extremely delicately balanced state into 
lethargy or catalepsy, labour is interrupted. Drs. Auvard 
and Sechegron record attempts by themselves and others 
to hypnotise a very large number of patients. Out of the 
whole group about a dozen women, of the hysterical type, 
proved to be hypnotisable. With these the condition lasted 
only through the second stage of labour, being broken into 
by the violent pains of the expulsion stage. 

Many obstetricians speak of the long-continued and 



152 AUTHENTIC TWILIGHT SLEEP 

exhausting pains of the dilatation or second stage of labour 
as harder on the mother than the short, frenzied agony of 
the expulsion stage. 

We have told how Steinbiichel substituted scopolamin- 
morphin for simple morphin with no other object than to 
give snatches of sleep between the tiring dilatation pains. 
Morphin is sometimes still used for this purpose. Many 
physicians who will not use scopolamin-morphin through- 
out labour, use it, not infrequently in the inferior form of 
the unstable hyoscin, for dilatation, using ether at the 
moment of delivery. Franklin S. Newell, of Harvard, 
frequently uses this combination, instead of Twilight 
Sleep throughout the whole birth. 

Another combination by which painlessness can be eked 
out throughout labour is codein, digitalin, and strychnia, 
with a dash of ether at the end. 

Antipyrin used hypodermically has not infrequently 
given some relief in the early stages of labour. It seldom 
does more than to lessen the suffering. This is also true 
of chloral. 

Dr. H. C. Adams, of New York, claims that a perfect 
painlessness throughout labour can be obtained by nitrous 
oxide and oxygen. 

This combination is becoming recognised as the safest of 
surgical narcotics, and both Dr. Allen and Dr. H. Bellamy 
Gardner, of London, believe it to be equally safe and effi- 
cacious in labour. 

It has the disadvantages of even the perfect chloroform 
a la reine or ether in demanding drop-by-drop adminis- 
tration and in subjecting the patient to all the disagree- 
able impressions that go with the administration of in- 



A DOZEN ANESTHETICS AND FORCEPS 153 

halation anaesthesia. In surgery scopolamin-morphin is 
often used so that the patient shall be spared the terrors 
and discomforts of the final inhalation. In obstetrics 
scopolamin-morphin in Twilight Sleep can do away with 
this inhalation entirely. 

Premature delivery by artificial means in the eighth 
month was offered one of the writers by an American ob- 
stetrician. Her pelvis was slightly smaller than the aver- 
age, and he feared that if he let her go to term the birth 
might be slow and painful. , "An eight months' baby 
should have at least as good a chance as a seven months' 
baby," said this doctor. At Freiburg later she was con- 
fined under the slow waiting method without pain. What 
premature delivery, as a means of lessening the mother's 
pain, means to the .child is expressed by Dr. A. van 
Couwenberghe : 

"It introduces into the world," says he, "a being whose 
organs are not perfectly developed and who is physiologi- 
cally insufficient, with muscular system undeveloped and 
circulation and respiration precarious." 

In proportion to the number of children born into the 
world there has, all told, been little pain-lessening at birth. 
In what relief has been given, the form that has been com- 
monest has been the "alleviating" forceps, with its dem- 
onstrated dangers to mother and child. All the other 
means have been for the majority of obstetricians too much 
trouble. Few have felt like Eeynolds that for the allevi- 
ation of pain the "time of the obstetric attendant is not his 
own." Hurrying from one case to another, both obste- 
trician and general practitioner have used the forceps, 



154 AUTHENTIC TWILIGHT SLEEP 

early or late in the labour, when the mother's patience or 
her strength was failing her. 

We have quoted Dr. Kronig before in regard to the 
forceps. He states the dangers to the mother even more 
exactly : 

"Although in the hands of a skilled operator the for- 
ceps is not so dangerous as in those of an inexperienced 
one, yet for those who know how great is the local suscep- 
tibility to infection it is hardly necessary to say that the 
chances of a favourable confinement and recovery are con- 
siderably diminished by any operation. 

"If you follow the lyings-in, even in the best hospitals, 
you will find the number of cases of temperature consid- 
erably higher where there was not spontaneous delivery. 
In the unfavourable external circumstances of ordinary 
practice, all these injurious results increase. The great 
increase of the spread of puerperal fever corresponds to 
the increasing frequency of operations shown in the sta- 
tistics of the larger towns. 

"It might have been thought that the introduction of 
asepsis in obstetrics, and its careful application outside 
the hospitals as well as in, would have decreased the num- 
ber of deaths in childbirth in comparison with those under 
former conditions. But we note a not inconsiderable in- 
crease. Every one agrees that the absence of reduction in 
the number of cases of puerperal fever is chiefly caused by 
an enormous absolute increase in the number of opera- 
tions, and especially a huge increase in deliveries by the 
use of forceps." 

Dr. Polak's arraignment of the forceps is even more 
startling. It shows that pain demands the relief of the 



A DOZEN ANAESTHETICS AND FORCEPS 155 

forceps in a way that is particularly injurious : that is, be- 
fore the birth process is far enough along to make it safe. 
Drs. J. Clifton Edgar, A. Lapthorne Smith, and Whit- 
ridge Williams have recently and forcibly pointed out the 
dangers to mother and child of its indiscriminate, prema- 
ture, and unskilled use by very many physicians attend- 
ing childbirths. But none of them express themselves so 
tellingly as Dr. Polak: 

"Many of us seem to forget that the cervix must be 
open before the child can pass through it; others delude 
themselves into the idea that they can artificially dilate 
the soft parts as perfectly as with nature's processes, and 
few of us give nature sufficient time to prepare the way. 
Dead and mutilated babies, torn and prolapsed organs, 
with resulting morbidity from infection, are some of the 
causes which have produced this public demand for adop- 
tion of the Freiburg method." 

Against no anaesthetic has a case been made as strong 
as this; and for one birth made spontaneous under some 
form of painlessness there are a hundred relieved by the 
forceps. 

Almost at the same moment that the facts about Twi- 
light Sleep were first placed before the public the news- 
papers announced in short paragraphs that France had 
discovered the perfect obstetrical narcotic. The clippings 
daringly called this drug itself, "Painless Birth." 



CHAPTEK X 
A French Experiment of To-Day 

Ribemont-Dessaignes, member of the French Faculty 
of Medicine, for years professor of Obstetrics at the Acad- 
emy, and head of Beau j on Maternity, is the first scientific 
advocate of painlessness in childbirth to base his whole 
case not on humanitarian grounds, but on the actual su- 
perior safety of the removal of pain ; checking up point by 
point the processes of birth and pointing out how many 
abnormalities and impediments in the birth process are 
removed by eliminating the element of pain. 

The abolition of the element pain from the element 
contraction was such a radical feat that it stripped the ob- 
serving obstetrician of most of his semaphores of custom. 
A new set of signals replaced the classic cries of antiquity. 
Hysterograph records were taken of the period of con- 
traction and of expulsion, and these showed the pains of 
undiminished vigour and regularity; these also showed 
that the contractions which after the first analgesic injec- 
tion were painful, were so for a diminished period each 
time, ending at the apex of a contraction with a mere flash 
of pain, after which the contractions continued with theif 
full volume, in perfect painlessness. 

A new world of obstetrics, in which the birth process 
could be followed as a supreme muscular function, was 

156 



A FEEISTCH EXPEEIME1STT OE TO-DAY 157 

opened to the breathless veteran obstetrician and his staff. 
An infinite variety of clinical proofs was collected, show- 
ing how quickly the drug acted on the pain element, and 
yet how neutral was its influence on the force of the con- 
tractions, while it seemed in some cases to hasten dilata- 
tion. The normal duration of the birth period, an aver- 
age of fourteen hours, was found not to be appreciably 
lengthened, and was even in some cases shortened. 

Eibemont-Dessaignes says in his report : 

"I am thus justified to affirm authoritatively that the 
labour is not lengthened under this analgesia; I am in- 
clined to think that it may, in certain conditions, be even 
shortened. !N"o obstetrician has failed to observe the de- 
spairing slowness with which dilatation progresses in some 
women, in spite of the fact, or perhaps because of the fact 
of the excessive violence of their pains. These women, 
directly they are in the state of analgesia, dilate with a 
remarkable rapidity. The spasm of the uterus which 
seems to be inhibited by pain, cedes as soon as this pain 
disappears. I have had many occasions to observe this. 
It is the same with a woman whose contractions are ac- 
companied with lumbar pains : labour is always longer in 
these cases. The suppression of these terrible pains, so 
apprehended by women, favours the regularity and rapid- 
ity of labour. The period of expulsion which comprises 
the passage of the foetal region that presents itself through 
the external orifice of a completely dilated uterus, its com- 
plete descent right down to the perineal floor, its intra- 
pelvic rotation, and finally its expulsion outside the genital 
organs, seem to me facilitated and shortened. 

"We can give two reasons for this: On the one hand, 



158 AUTHENTIC TWILIGHT SLEEP 

the woman whose dilatation presents itself while she sleeps 
and who has not suffered, is full of confidence and courage, 
and as the particular sensation which carries by reflex the 
necessity of making an effort, never fails, the woman 
pushes, to use the classic phrase. She pushes silently, but 
she pushes with all her force, happy to feel the progress 
of her child which each effort brings nearer the goal. On 
the other hand, the muscles of the perineum allow them- 
selves to distend and do not react as they usually do." 

Like Kronig and Gauss, Ribemont-Dessaignes stands 
amazed at what the removal of pain means to the conva- 
lescence. He likens the recovery from shockless child- 
birth to the recovery from shockless surgery, instancing 
the importance that American surgeons, the Mayo 
brothers in particular — to whom he might have added 
Crile — attach to such shock elimination. "Our patients," 
he says, "have experienced no shock, no exhaus- 
tion; feeling not even fatigue, not even mental anxiety; 
they have undergone no physical duress; we do not ob- 
serve in them the depression, the nervous excitement so 
often seen. 

"Those mothers of many who are subject to violent 
after-pains have observed with delight that the pains they 
were expecting did not come, as such births have been 
quick and the analgesia has lasted beyond the birth." 

While Kronig and Gauss found the readjustment of the 
organs after birth to be perfectly normal, Bibemont-Des- 
saignes has found this readjustment positively aided. 
"The involution of the uterus and in consequence its 
re-entry into the pelvic cavity are manifestly accelerated, 
as the bottom of the organ, by the end of the ninth or 



A FRENCH EXPERIMENT OF TO-DAY 159 

tenth day, met the symphysis pubis, in all my cases, who 
all nursed their babies." 

Both Pinard and Ribemont-Dessaignes express enthusi- 
astic satisfaction at having had their patients already in a 
condition of analgesia in those cases where minor opera- 
tive interference is suddenly found necessary, such as 
manual assistance in the birth, stitching after lacera- 
tions, etc. 

It is curious comment on the attitude towards pain in 
labour, that even the sympathetic obstetrician in the hos- 
pital is not in the habit of troubling to give a few moments 
of anaesthesia for these stitchings after lacerations; for 
Prof. Ribemont-Dessaignes says naively: "These few 
stitches, when necessary, have heretofore been very ill 
received by the patient." 

He and Prof. Pinard have also added their experience 
to the accumulation of evidence, coming from all parts of 
the obstetrical world to-day, that artificial painlessness is 
an ideal method of treating eclampsia, those convulsions 
due to uremic poisoning, that are not unusual in child- 
birth or late pregnancy. 

The story of Antalgesine is the story of an experi- 
ment. 

It is not to be confounded with the authoritative method 
of painless birth at Freiburg. Until there is a sufficient 
body of statistical data on which to base a judgment, it 
must be looked upon as an experiment, but an experiment 
which has the endorsement of the greatest men in French 
obstetrics to-day. It may be only the whirlwind of enthu- 
siasm dying out, for the most part in failure, that followed 
Steinbiichel's first use of scopolamin-morphin. Ribemont- 



160 AUTHENTIC TWILIGHT SLEEP 

Dessaignes' 112 cases prove no more than Steinbiichers 20 
cases, and we know the disappointment that followed them, 
before the proper use of scopolamin-morphin was worked 
out. 

"We wanted something for the provinces," said Pro- 
fessor Ribemont-Dessaignes, the dean of obstetrics in 
France. "We think we have found it." 

What the French obstetricians believe they have found 
is that they can achieve painless childbirth by means of 
this new drug more simply than Kronig and Gauss have 
done with Dammerschlaf or Twilight Sleep. It is a won- 
derful thing that on the basis of a study of some one hun- 
dred cases, French clinicians have spoken with such 
enthusiasm for Antalgesine and have put it into imme- 
diate use in their own clinics. They wanted something 
for the provinces; the provinces produced it and gave it 
to Paris; Paris has received and given it back. But it 
has not yet received the seal of the French Academy of 
Medicine. 

The pharmacologist, Pouchet, gave Ribemont-Des- 
saignes the following memorandum : 

"From a chemical point of view the drug comes very 
near the oxydimorphin of Marme ; it seems to be a product 
of hydration and hydrogenation of morphin, of which it 
possesses not one of the chemical reactions supposed to be 
characteristic. It precipitates but little all the general 
reactives of the alkaloids. 

"From the physiological point of view, it constitutes a 
substance embodying extremely interesting pharmaco- 
dynamic properties. If one may so put it, it places the 
animal organism in an exquisite state of receptivity 



A FKENCH EXPEKIMEET OE TO-DAY 161 

towards such medicaments as strychnin and digitalis, of 
which it attenuates in a considerable degree the toxic mani- 
festations, and in a totally different fashion than is realised 
with morphin. 

"Like this last, it manifests very accentuated vasomotor 
reflexes, and exercises a remarkable action on the respira- 
tory mechanism. The reflex excitability is very decidedly 
exaggerated. 

"Its influence exerts itself in a very special way on 
the brain and the great sympathetic nerve. 

"In animals it differentiates sharply from morphin by 
a marked excitement of the salivary and intestinal secre- 
tions, also of the urinary secretions, but in a minor 
degree. . . . 

"The cerebral influence manifests itself at the start by 
something that resembles inebriation. 

"Used intravenously its effect is instantaneous. A dog 
injected intravenously with 1 cc. fell headlong asleep and 
slept profoundly and without interruption for more than 
12 hours." 

In Kibemont's experience, antalgesine produced com- 
plete painlessness in about fifteen minutes; in the hands 
of an experienced hypodermic anesthetist, who might wish 
to use it intravenously, it can be effective instantly. It 
was effective even when employed late in labour, as severe 
pain does not interfere with its first action. It required 
no special environment, and could be employed in private 
practice or the noisy ward of the hospital. Its character- 
istic is the abolition of pain perception in full conscious- 
ness ; this is so typical that the chemist who worked with it 
for two years believed firmly that its influence was local, 



162 AUTHENTIC TWILIGHT SLEEP 

not cerebral, as is really the case. It appears to stimulate 
muscular activity in labour, and to bave a much stronger 
narcotic effect than morpbin. Its use in cbildbirtb in 
France has been entirely without disagreeable after-effects 
on the mother. This is also true as shown in the reports 
published by an American obstetrician, although the 
American experience is at present too slight to be of more 
than corroborative interest. 

But what is of importance is that the leading obstetri- 
cians of France have now spoken emphatically for painless 
childbirth, not alone from the point of view of its humane 
desirability, but for its value to obstetrics. The discovery, 
by Georges Paulin, of a drug which can be employed to 
induce and maintain painlessness over a long period, with- 
out prejudice to muscular activity, and without the 
meticulous care and environment necessary to Twilight 
Sleep, has made their occasion. The drug placed in their 
hands is ideally suited to the sceptical French tempera- 
ment; for in France, as an anecdote of Prof. Ribemont's 
will presently show, none too much blind confidence is 
placed even in the most illustrious practitioner; and 
French women who desire painless babies prefer to have 
the painlessness induced in such a way that they do not 
lose their alert consciousness of the situation. 

Prof. Ribemont-Dessaignes' formal report, which covers 
an experience with 112 cases in which the new drug had 
been used, was made at the July 21st meeting of the 
French Academy of Medicine. This report is published 
as Bulletin 28 of the Academy of Medicine for 1914, by 
Masson et Cie, Paris. 

Prof. Ribemont-Dessaignes has for many years been 



A FRENCH EXPERIMENT OF TO-DAY 163 

professor of obstetrics of the Faculty of Medicine, and 
head of the Beau j on Maternity, near the Ternes. He 
shares with four other French specialists the curious 
French designation of "Accoucheur des Hopitaux" His 
colleagues under this title are Pinard, Couvelaire, Bazy, 
and Hartmann. 

Therefore the effect of his communication to the Acad- 
emy was, as French clinical papers put it, "retentissante." 
It was, indeed, heard round the world, and was the last 
message of obstetrical science in Europe before the war 
preparations dropped the curtain of silence. It reached us 
in Germany by way of a clipping from a Chicago paper. 

In Germany it was not possible to obtain a copy of 
Bulletin 28 ; obstruction of the mails followed too closely 
on the heels of mobilisation. 

It was not possible in London. We learned, on reaching 
London from Freiburg, that this extraordinarily interest- 
ing document would not be received at the British Med- 
ical Association Library until after the close of the war. 

So we went to Paris for it. Paris afforded the oppor- 
tunity for several talks with Professor Ribemont-Des- 
saignes, as well as with friends of the chemist whose dis- 
covery perhaps places an entirely new drug at the service 
of obstetrics. And lest it should be laid at Professor 
Ribemont's door that he lent himself to a journalistic 
interview, we may as well confess that it was not as 
journalists that we approached him, but as students of 
obstetrical semi-ansesthesia. 

It was just a few days after the removal of the French 
Government to Bordeaux. Paris was a city of closed 
houses and of shops whose window fronts bore hastily 



164 AUTHENTIC TWILIGHT SLEEP 

scrawled legends such as: "The proprietors having gone 
to join their reserve regiments and the employes having 
been mobilised, these premises are left in the care of the 
public." 

But at the doctor's house, near the Arc of Triumph, in 
a quarter deserted by all except the American Embassy, 
we learned that although it was the hour of Prof. Kibe- 
mont-Dessaignes' consultation, he was out attending to the 
work devolving on him by reason of the absence at the 
front of his younger associates. 

Later we found him at home. Like many of the older 
Parisians who stayed at their posts during the approach 
of the Prussians, he was entirely alone. How literally 
alone such men stayed while families and. women servants 
refugeed to the Normandy coast and the men servants were 
mobilised, was evidenced to a visitor in the simplest way. 
They opened their own doors. 

Small, wiry, impulsive, humorous, the celebrated scien- 
tist recalled the well-known American figure of Gen. Joe 
Wheeler. We were not surprised to find him much cast 
down that age limitation barred him from serving in 1914 
as he had done in 1870. He was getting what compensa- 
tion he could out of the routine work of his hospital and 
city practice ; enthusiastic about his new drug and employ- 
ing it in every case where the patient consented. 

"It is all Paulin' s work," he said modestly. "Paulin — 
the chemist. He's the man that has invented the drug. 
He called it at first 'Tocanalgine' — 'Painless Birth.' It is 
now 'Antalgesine.' 

"A friend of mine, Dr. Laurent, brought Paulin to me. 
Laurent had had some cases where he had used the Antal- 



A FKEISTCH EXPEKIMEISTT OF TO-DAY 165 

gesine. He was enthusiastic. I was soon satisfied they 
had something I could not do better than investigate." 

In the small hours of a winter night about two years 
ago, the new drug, Antalgesine, was a nameless ferment in 
a great jar sitting on a shelf in the suburban laboratory 
of Georges Paulin, a French chemist. 

To Paulin, whose laboratory window shed the only 
light abroad in the sleeping village, came the frenzied hus- 
band of a woman at the point of collapse from agony in 
labour. The doctor had sent him out to get morphin. 

Of morphin Paulin had none, now. He had put all 
he possessed into the vegetable ferment, like beer leaven- 
ing, that was at work in the jar on the shelf. The result 
was a product possessing not one of the chemical reactions 
supposed to be characteristic of morphin, but retaining its 
narcotic qualities. He had some of this new preparation 
in a form suitable for hypodermic injection, and had 
experimented with it as a local anaesthesia. 

The emergency was pressing. Taking enough of the 
new preparation to make three or four injections, he 
accompanied the husband back to the doctor at the pa- 
tient's bedside. After a hasty consultation together, doctor 
and chemist risked an injection. 

For some five or seven minutes the agony was unabated. 
Then the remarkable virtue of the new drug began to 
show itself. At the end of a quarter-hour the pain had 
gone as by a miracle but the birth was progressing unin- 
terrupted. A few hours later the child was born, pain- 
lessly. 

Doctor and chemist withdrew as the sun rose on that 
ecstatic household; both practitioner and analyst were 



166 AUTHENTIC TWILIGHT SLEEP 

dazed, incredulous ; yet both had seen, and both knew that 
the fact established was a revolutionary one in obstetrics. 
Morphin had been used in a form that had proved harm- 
less to the mother and child, and had produced total immu- 
nity from pain, allowing the birth to progress normally. 
It had accomplished a scientific miracle. 

If either of these men had heard of the Freiburg 
method of painless childbirth, they had years ago dis- 
counted it, and classed it with those French experiments 
in chloral, chloroform, opium and morphin which failed. 
So to them the miracle at which they had assisted was the 
first truly painless birth in which the muscular action had 
not been inhibited, nor the birth retarded. And they 
named the new drug after the miracle: Tocanalgine, 
Painless Birth. Later the name was changed to Antal- 
gesine obstetrique. 

The doctor, in sending for morphin, had expected to 
use it in infinitely small doses to give sleep momentarily, 
between pains. For to have used simple morphin in an 
amount sufficient to produce analgesia would have been 
to endanger both mother and child. This fermented mor- 
phin had produced analgesia without toxic effects, for it 
had what afterwards proved to be but one-fifteenth of the 
toxicity of morphin alone. 

For days afterwards, doctor and chemist talked about 
it; the neighbours talked about it. It seemed as if one 
of the great fundamental laws of nature had been set to 
one side. It would revolutionise obstetrics. Meanwhile, 
another hard birth coming along in his practice, as these 
cases seem to run in groups, the doctor used the new drug 



A FRENCH EXPEKIMEOT OF TO-DAY 167 

again, and again had the miracle of painless "birth unat- 
tended by unpleasant after-effects. 

Paulin began to be on the lookout for cases in which 
women could be persuaded to seek the relief of the strange 
drug. The cases were few in a little French village where 
prejudice is deeply rooted against the new and strange. 
It had indeed worked for this one and that one, who 
proudly exhibited their glowing babies ; but might it not 
fail to work in the next case? Both doctor and chemist 
dreaded that next case, hypothetic though it might be : the 
case in which a still-born baby, dead perhaps two days 
before the drug was injected, would be laid at the door of 
the drug. Still, as it became known that the chemist, who 
was much respected and looked up to by the village, would 
personally bear the expense of one's confinement if one 
consented to be delivered under the painless drug, a num- 
ber of patients came forward who would otherwise have 
contented themselves with the doubtful sepsis of the village 
midwife. 

Paulin considered his resources, and fitted up a small 
hospital, or lying-in home, to which patients could come 
and have their confinement as free as in the maternity 
hospitals. For this small private hospital, it was his idea 
that he could employ the highest obstetrical talent in 
Paris, thereby introducing to them the drug which, under 
the expressive name of Tocanalgine, he was offering to 
them in sample packages. 

The obstetrical talent of Paris, in the persons of one 
or two of its exponents, came when summoned, for the 
actual delivery alone, and scoffing at the analgesia that they 
were at no pains to observe through the period of labour, 



168 AUTHENTIC TWILIGHT SLEEP 

refused to take any interest with what they probably set 
down as a novel form of chemical advertising. 

Paulin found himself paying Champs filysees fees for 
the confinements, in his private hospital, of his charity 
patients, without there being roused in the minds of the 
fashionable practitioners an idea that there was anything, 
scientific or otherwise, to be investigated in this unusual 
experiment. The hospital conformed to the city require- 
ments; beyond that it might have been the harmless fad 
of a man of means gone daft on a fixed idea. They still 
refused to have any responsibility for Antalgesine ; it was 
still impossible to introduce it experimentally into any 
of the great maternity hospitals. 

Two years of apparently futile effort passed in this 
way. They were not entirely futile, for Paulin the 
chemist was very nearly qualified to pass an examination 
as Paulin the obstetrician, so closely had he studied the 
cases under his drug, and so minutely had he kept records 
of its singular influence, during the birth process. The 
country practitioner who had watched through the first 
case with him had remained an interested observer of 
Paulin's efforts to get the drug before the influential men 
of Paris. He now offered to personally take Paulin and 
present him to Ribemont-Dessaignes. 

"He will laugh at us," he explained, showing that he 
had been intimidated somewhat by Ribemont's levity, 
"but if he says he will try it, you can rest easy that he'll 
give it a perfectly fair try-out." 

"I did laugh," Prof. Eibemont acknowledges. "But I 
listened, too. I looked over the informal reports Paulin 
had ready to show me. I promised to give the stuff a try- 



A FRENCH EXPERIMENT OF TO-DAY 169 

out, not simply at Paulin's hospital, but at the Beaujon 
Maternity. I personally administered the drug in the way 
practised in Paulin's hospital, and at once became ab- 
sorbed in observing its influence. I instantly appreciated 
that I had to do with a discovery. 

"On the day when I made my own first experiment 
with it, I invited both Dr. Laurent and Dr. Paulin to be 
present. 

"There were three parturient women in the ward at 
the Beaujon Maternity. Two were having their first 
child. The third was already a mother of several. All 
three, as I will show you presently, were having a very 
hard time of it. Their agitation and their energetic cries 
testified to the intensity of their pains. 

"Approaching Number 1, I offered to assuage her suf- 
fering, but was not at all cordially received. 'I am not 
so anxious to die,' she declared. 

"The second refused less brusquely; nevertheless, she 
refused. 

"The third one — you'll remember, the mother of many 
— accepted at once, and I injected into her one cubic 
centimetre of the solution. Up to this time the labour had 
showed itself to be very regular, and the contractions very 
severe, coming back every five minutes. Exactly Rve min- 
utes after the injection the contraction came, accompanied 
by a pain which seemed of shorter duration than the pre- 
ceding ones. Another five minutes passed and a new 
contraction came, this time noticeably less painful. Five 
minutes later, the uterus contracted again, but unaccom- 
panied by pain. I was, I admit, very much impressed. 

"Tremendously impressed, also, were the occupants of 



170 AUTHENTIC TWILIGHT SLEEP 

the other two beds. These women had not missed a word 
as to her lessened pain that Number 3 furnished, and at 
the end of a few minutes, Number 2 requested that I give 
her the injection that had so miraculously relieved Num- 
ber 3. I made the injection, and saw her experience, 
first, a shortening of the duration of the pain, then a les- 
sening of its intensity, and finally, its entire abolition at 
the end of 15 minutes. 

"Number 1, now quite reassured that it would not kill 
her, screamed lustily to be relieved in the same marvellous 
way ; and without holding her previous prejudices against 
her, I gave her the injection, and soon, like her neighbours, 
she was free from pain. 

"In the ward, which up to now had been filled with 
screams, there reigned an imposing silence. 

"I went from one to another, and noticed not without 
astonishment that the rhythm of the uterine contractions 
seemed not to be noticeably modified. Labour continued 
regularly and painlessly in all three women. 

"The first one was delivered a few hours later without 
suffering. The second one, in whom the pelvis was very 
narrow, and whose child showed a forehead presentation, 
had to be delivered in the evening by the aid of forceps ; 
the mother of many, whose child had been dead for four 
days, had to be delivered in the same way. They had 
been spared untold suffering. 

"In my subsequent experiments I used the drug 
wherever the labour seemed very painful, or the birth 
promised to be very long. Now, I use it in almost all 
my cases ; in all, in fact, that do not refuse it. 

"The drug acts on the nerve centres, on the brain and 



A FRENCH EXPERIMENT OF TO-DAY 171 

sympathetic nerve, and is carried from the point of injec- 
tion to the nervous centres by the circulatory system. 

"A certain number of women arrive at the hospital 
in an advanced stage of labour; in these the analgesia 
prolongs itself beyond the duration of the confinement. 
With this reservation, the average of the duration of anal- 
gesia in women who required but a single injection — of 
which we had 63 in our first group of 112 cases, or more 
than half — has been seven hours. In 39, the contractions 
became painful again at the end of ^.ve hours, on the 
average; they then received a second injection, thanks to 
which the labour terminated without pain. In 9 cases, it 
was found that after an analgesia that was more or less 
durable, it was necessary to give a third injection." 

This is the picturesque story of the first administra- 
tion of antalgesine at the Beau j on Maternity, and the very 
general statement of its gradual adoption through the 
service. Since these first experiments its use has spread 
to all the other maternity hospitals of Paris, and has been 
welcomed by such an illustrious colleague of Ribemont- 
Dessaignes as Pinard. The experience in the drug in the 
various hospitals now covers many hundreds of cases and, 
after the war, there will probably be many reports on it. 
What they will bring out remains to be seen. 

Antalgesine is still in its experimental state. There is 
no report published except that of Ribemont-Dessaignes, 
and a first part of a carefully analysed report on later 
cases by Dr. Le Laurier, who was called to the war before 
part two and part three, which were to contain the impor- 
tant facts of his experience, were ready for the press. 



172 AUTHENTIC TWILIGHT SLEEP 

Pinard makes a short statement, noting, like Ribemont 
himself, a small percentage of refractory patients. He 
notes a greater variableness of effect than the others both 
in respect to state of consciousness attained in different 
patients and to the duration of painlessness from one dose. 
Others note a longer passage of time before the drug pro- 
duces painlessness. Still others note a difference in char- 
acteristics when the drug has aged. Pinard's report 
nhows that the characteristics are not yet fully studied, 
but he is, like the others, enthusiastic about the value of 
painlessness, and the promise of the particular drug. 
Pinard is also the one who speaks most emphatically on 
its harmlessness, and even what he considers its decided 
advantages to the child during the birth process, and the 
entire absence of prejudicial after-effect. 

Gauss of Freiburg passed through the period of alarm 
over the oligopnceic baby who came sleepy into the world ; 
later, he considered it of little importance; later still, he 
began to feel that the sleepy child had in some cases a 
safeguard against one of the common dangers of the birth 
process: that of breathing prematurely and inhaling 
injurious fluids into the bronchial tubes. 

Pinard of Paris does not throw this out as a sugges- 
tion. He confidently enumerates this oligopnoeic condition 
among the advantages of the use of antalgesine. "It seems 
likely," says he, "that this influence may be of great value 
in cases where premature respiration is to be feared." 

Kibemont-Dessaignes goes farther. He establishes by 
experimentation this positive value of painlessness in some 
cases suggested tentatively by Kronig and Gauss, and pro- 
claimed without question by Pinard. "These children," 



A FKENCH EXPEKIMENT OF TO-DAY 173 

Kibemont-Dessaignes declares, "who have never felt the 
need of breathing before birth, have their respiratory 
passages free from all foreign obstruction. This is much 
more marked in the case of those who by reason of um- 
bilical cord entanglement, low implantation of the pla- 
centa, breech extraction, and narrow pelvis, etc., are born 
in a true state of apparent death ; in these aspiration drew 
out neither amniotic fluid, nor mucous substances, nor 
meconium. The drowsiness of the foetus made it unsus- 
ceptible to the need for premature respiration. I saw 
four of these cases." 

An American obstetrician in whose hospital service 
Twilight Sleep was being tried obtained a few sample 
ampoules of antalgesine, and turned them over to his chief 
of staff, who was able to use it on three cases. In his 
brief summary of these cases before the Obstetrical Divi- 
sion of the Academy of Medicine, he said: 

"Though my three cases with antalgesine were not 
everything to be desired I assure you they were much 
more successful and more encouraging than were my first 
attempts in the Kronig-Gauss method." 

This exactly bears out Prof. Bibemont-Dessaignes's 
claim for antalgesine "for the provinces" : it is easier to 
use with relative success. 

In concluding a brief report this American physician 
says: 

"In comparing scopolamin-morphin and antalgesine, 
certain points should be taken into account: Both act on 
the central nervous system. Antalgesine works in fifteen 
minutes; scopolamin in from one to three hours. Both 
fail in a small percentage of cases. Both are harmless 



174 AUTHENTIC TWILIGHT SLEEP 

to the mother. Both probably prolong the second stage of 
labour, but a slight prolongation is rather a benefit than a 
harm. Both cause oligopnoea in a certain number of cases ; 
in my antalgesine cases two out of the three were oligop- 
noeic; Kibemont's experience is 25 per cent, of oligop- 
noea — a larger proportion than in any series of confine- 
ments under Twilight Sleep, but Professor Ribemont- 
Dessaignes notes this peculiarity : where he has used antal- 
gesine that has been over six months aging, oligopnoea 
has not been observed. 

"Though I am delighted with the results I have obtained 
with Twilight Sleep, I would welcome a drug that was 
just as safe for mother and child as scopolamin-morphin, 
and easier of manipulation. In the Freiburg method, the 
memory test, not always easy to employ, must be repeated 
every few minutes, and the mother and child must be con- 
stantly watched. With antalgesine, the return of the ob- 
jective signs of pain means that the effect of the drug has 
worn off, and the patient needs another injection; the first 
dose can be given near the end of labour as it works 
promptly and its action is not impeded by pain." 

These conclusions, though based on too few cases to 
assume authority — for three cases, or 112 cases, is too 
few to carry conviction — suggest to advocates of painless 
birth both the strength and the weakness of antalgesine 
if it fulfils its promises. However optimistically Ribe- 
mont-Dessaignes may look at it, the proportion of oligop- 
noea is too large. Maybe the percentage will be lessened 
progressively as it has been with Twilight Sleep. 

Obstetricians in America have been amazed at the in- 
structiveness of Dammerschlaf. As one of them said re- 




Professor Weis main's Great-grandchild, born under Dammerschlaf 
in 1913. Professor Weismann was the contemporary of Darwin. He 
was emeritus professor of biology at the University of Baden, and 
died at Freiburg in 1914. 




Courtesy Miss Alice Boughton 

Mrs. Joseph A. Sargent and William Winthrop Horne Sargent, 
one of the youngest of the American boys born at Freiburg. His 
family came up from Spain that he might be a Dammerschlaf baby. 



A FRENCH EXPERIMENT OF TO-DAY 175 

cently: "It is making our interns learn obstetrics." By 
demanding constant observation and hospital environment, 
it is already taking the first steps towards making of child- 
birth the work of the specialist, and not a mere occasional 
incident in the work of a busy general practitioner who 
having delivered his three cases under direction in college, 
must thereafter rely for further knowledge on his personal 
experience as it comes to him. An alternative to Dammer- 
schlaf, especially one under which the patient can scarcely 
be said to lose consciousness any more than under local 
anaesthesia, should be welcomed heartily, 'provided its ap- 
plicability to provincial or untrained usage does not retard 
the scientific development of obstetrics now promised by 
Twilight Sleep. 



CONCLUSION 

The Obstetrics of To-mokrow 

"This may be called the gentle age of obstetrics," said 
A. Lapthorne Smith before the American Gynecological 
Society in 1911. "Brute force and roughness have been 
replaced by wise judgment and gentle skill." 

The age may be gentle when compared with that of 
Laurence Sterne, but that much of the obstetrics is still 
as primitive as those described in Tristram Shandy is an 
incontestable fact. In a talk before the Twilight Sleep 
Association Miss Tola La Follette described a confinement 
which was in the hands of a general practitioner. The 
case required csesarean operation. The general practi- 
tioner had not had the knowledge to diagnose it. He let 
the birth progress to an acute stage, and then suddenly 
the situation was taken out of his hands ; needed the spe- 
cialist; and he was obliged to call an ambulance, and 
putting the patient into it, jolt her in her agony and 
extremity to the nearest hospital where there was a surgeon 
competent to perform the cesarean section. 

Only in time of accident or war would a man be sub- 
jected to such medical care as this. Yet the "wise judg- 
ment and gentle skill" of the general practitioner, who is 
always considered adequate for confinements, are never 
able to cope with such emergencies as this ; and childbirth 
is distinctive for its sudden and vital emergencies. 

176 



THE OBSTETEICS OF TO-MOKKOW 177 

Dr. A. B. Davis, Professor of Obstetrics of the Univer- 
sity of Pennsylvania, gives ns an idea of how common 
such situations are in private practice: 

"We are positive that many lives of mothers and infants 
are lost each year and many others are left more or less 
permanently physical wrecks who could have been saved 
by the timely employment of caesarean section." 

Fifty years ago, the surgeon was despised. He was re- 
garded as a degree below the general practitioner. He 
was generally the barber, and the barber's pole still has 
the streak of blood wound about it. 

The general practitioner clings to his births for the 
small fee they bring in, but he dislikes them for the time 
they take and for the emergencies that may arise in them. 
There have come into existence two other classes of med- 
ical men: the obstetrician who specialises in births, and 
the gynaecologist, whose main function is to repair the 
damages done by the general practitioner in conducting a 
birth. Dr. J. O. Polak puts at fifty per cent, of all gynae- 
cology the amount of it which is due to badly conducted 
births. 

The obstetrician, better equipped to learn from his own 
experience, has an opportunity which never comes to the 
general practitioner with his occasional births in his prac- 
tice, but he suffers from some of the contempt that the 
surgeon suffered from when surgery was becoming a 
science. In medical schools the professor of midwifery 
is looked upon by his colleagues as being engaged in an 
almost unworthy pursuit. The professor of gynaecology, 
who has the care of a woman in all the pathological phases 
of her sexual life, generally considers the bringing of a 



178 AUTHENTIC TWILIGHT SLEEP 

normal life into the world, that is, pure obstetrics, beneath 
him. 

The professor of obstetrics, midway between the gen- 
eral practitioner and the gynaecologist, is not himself 
equipped to meet all the emergencies of a birth or of mor- 
bidity following a birth. 

Many childbearing women to-day are brought ultimately 
into the hands of the gynaecologist through the incomplete 
equipment of the men who have brought the children into 
the world. They are sufferers for the limitations of their 
present-day obstetrics. By raising the obstetrician to the 
grade of the fully equipped gynaecologist and by equipping 
the gynaecologist as thoroughly for obstetrics as he is now 
equipped for gynaecology, the fifty per cent, of gynaecology 
which is at present attributed to bad obstetrics may be 
done away with. 

"Neither gynaecology nor obstetrics," says J. Whitridge 
Williams, of the Woman's Hospital, Baltimore, "will take 
a proper place until a body of men has been developed who 
will be interested in, and devote themselves to, the study 
of the problems connected with the entire sexual life of 
women. I hope to live to see the day when the term 
obstetrician will have disappeared and when all teachers 
will unite in fostering a broader gynaecology instead of 
being divided as at present into knife-loving gynaecologists 
and narrow-minded obstetricians who are frequently little 
more than man midwives." 

With anaesthesia and the modern hospital the barber- 
surgeon has disappeared. With obstetrical anaesthesia 
and the perfectly equipped Twilight Sleep hospital the 
man midwife should disappear also, and the gynaecologist- 



THE OBSTETRICS OF TO-MORROW 179 

obstetrician be tbe equal of the surgeon. In tbe future 
he may be considered his superior, since the expert bring- 
ing of life into the world is part of preventive medicine 
while surgery is only repairing. One represents the way 
in which we are meeting, and trying to humanise mor- 
bidity and death; the other should represent the way we 
meet life and the prevention of morbidity. 

"We educate the public," says Dr. Polak, "how to pre- 
vent disease. It is going to educate us how to prevent 
many of the disasters of childbirth by insisting on better 
antepartum and interpartum care." 

The death-rate in all civilised countries is smaller than 
the birth-rate ; the suffering at birth is, therefore, greater 
in volume than the suffering at death. 

Part of the mortality rate and the morbidity rate of 
the world is caused by injuries to mother or child at birth. 
Dr. E. Gustav Zinke, a recent president of the American 
Obstetric Society, not long ago made the statement that 
in the face of the progress of scientific medicine, except 
for those cases cared for in the hospitals, the maternal 
and foetal mortality and morbidity from childbirth has 
not diminished in the last twenty years, and this is borne 
y out by figures gathered by Dr. Ellice McDonald. 

The form of obstetrical anaesthesia which brings the 
mother and child under the expert care of the perfectly 
staffed and equipped hospital is the one hundred per cent, 
perfect method of the future. 

"We have reached an age," says C. Foulkrod, Obstetrician of Jef- 
ferson Medical College, "when to accomplish any purpose it requires 
more than the feeble cry of one or two men on one night in a 
meeting to produce results. We must dignify the idea with the 



180 AUTHENTIC TWILIGHT SLEEP 

volume of a movement, we must back it by publicity, we must 
sting the doctor through his patients' brains to greater expertness 
or to an awakening that such a movement is abroad. 

"A day will come when all our babies will be born in hospitals. 
Enough hospitals for the purpose would cost less than our filter 
plants against typhoid. 

"In any maternity case the apparently simple and normal may 
be in the fraction of a second changed to the most serious. 

"We have reached the time after years of waiting when the de- 
livery of a baby is conceded to be a surgical operation. This so- 
ciety should take up a crusade to have such surgical operations 
performed in hospitals, where they belong." 

Scientific surgery and the splendid modern hospital 
have grown together out of the humane practice of anaes- 
thesia, and expensive as surgery is, it is practised in the 
same way in the free wards as in the private ones; the 
operating room and the conditions of operations are 
identical. 

The humane practice of Dammerschlaf will raise ob- 
stetrics also to a costly science. Dr. Birchmore hails the 
"hyoscin sleep" as that form of painlessness on which 
that great improvement of the obstetric art for which we 
have all been looking can be grounded. 

A new view of the value of life will be fostered. To-day 
the sense of its cheapness is so strong as even to stupefy 
society into habitual phlegmatic acceptance of its pain. 

Birth is reckoned by the average family at a cost of 
$25. The same family, confronted by the need of an 
operation, goes to the free or the cheap wards of the 
hospital, where the difference between the large expense of 
highly specialised work and what that family can pay is 
met by the community. 

The safeguarding of childbirth is even more the con- 



THE OBSTETEICS OF TO-MOEEOW 181 

cern of the community, and would cost no more, as Dr. 
Foulkrod has estimated, than the now awakened commu- 
nity feels justified in paying towards the prevention of a 
single disease. 

The life of the child is now reckoned at this $25 valu- 
ation, and the result is a devastating stream of cheap life. 
The humanising of birth, and the raising of its valuation 
to an average of the estimate of a maternity hospital, $85, 
for a birth will not make life commoner. The child's 
life and the mother's will be held less cheaply, and will 
be of more worth, in consequence, to the community. 

Kronig gave two messages to the women of Freiburg. 
For the first, the elimination of pain from childbirth, the 
women of Freiburg were ready. For the second, the 
women. of Freiburg were not quite ready, but the gyne- 
cologists of Germany were agreed at their last meeting 
when they resolved that for the sake of the mother their 
association should stand for family limitation. They pre- 
ferred fewer lives better born and better nurtured to many 
cheaply born and cheaply nurtured. 

The message of Gauss is to the profession. Eight years 
ago they took it, and acted upon it, in bad faith. To-day, 
taught by the women who kept faith with Kronig, the 
profession now says : "How strange it is that the Gauss 
technique has lain idle in medical literature with no one 
taking advantage of it." 

Simpson's message was never placed before the women 
of his day and has lived only in the practice of the very 
few most hypersensitive and sympathetic of his profession. 

The women who went to Freiburg, and women who will 
never go to Freiburg, look upon the little Frauenklinik 



182 AUTHENTIC TWILIGHT SLEEP 

in the metropolis of the Black Forest as their promised 
land. 

One American obstetrician, whose plan for a central 
hospital with a chain of small obstetric hospitals all over 
the country working in close touch with it, is the most 
comprehensive for meeting the new demand for painless 
birth and better obstetrics, says : 

"It will become necessary to establish local hospitals 
where the physician may send his patient to have the Twi- 
light method administered by a nurse or physician trained 
in this method. When the time of delivery approaches the 
physician may be notified so that he may deliver the child 
in the hospital. This seems to me the practical solution 
of the problem of how the large mass of the population 
are to receive the benefit of Twilight Sleep ; for, of course, 
it becomes impossible for a man with an active general 
practice to give the uninterrupted attention to his obstetric 
cases that the Twilight method demands; and unless con- 
tinued observation of the patient in Twilight Sleep is 
carried out by some one accustomed to the technique, it is 
better not to attempt the method at all." 

This is an expensive demand ; it means the reorganisa- 
tion and the raising of obstetrics. 

Its outcome will be painless spontaneous birth on as 
universal a basis as painless surgery. Its final outcome 
will be to relieve one-half of humanity from its antique 
burden of a suffering which the other half of humanity has 
never understood. 

It is only since they have heard the promise of the 
Twilight Sleep that the burdened half of humanity have 
themselves begun to express articulately the underlying 
tragedy of maternity. 



HOW IT FEELS TO TAKE THE 
TWILIGHT SLEEP 



HOW IT FEELS TO TAKE THE TWILIGHT 
SLEEP 



The Freiburg Experience of 
Mrs. Cecil Stewart 

When I first decided to go to Freiburg to have my 
baby, I did not believe I would have a really painless 
child. 

We had been able to get so very few facts about Twi- 
light Sleep and about Freiburg, for we were in America, 
and Mrs. Emmet, the only one who knew about it, was in 
Europe. To all our queries, she wrote back, "The Head 
ISTurse will tell you everything." 

My sister and I reached Freiburg after a long, tiring 
journey. We had come from London where I had been 
so ill that I had contemplated staying there for my baby, 
although I had come from America to have the Freiburg 
Dammerschlaf. The doctor in London seemed to think 
there was no necessity for rushing to Freiburg for this 
Twilight Sleep. He said he could give it to me himself, 
in London. But he warned me that it would be very 
expensive, while at the same time he treated it rather 
lightly, and I was more than ever determined to go to 

185 



186 AUTHENTIC TWILIGHT SLEEP 

Freiburg where it would be administered with enthusiasm 
if at all. So, as I was decided to go on to Freiburg, he 
gave me a letter to Kronig, assuring me that I would like 
his German confrere. 

We got to Freiburg the middle of a cold, wet, dismal 
October night. I was so ill and tired and lonely that I 
made up my mind to go right back to England the next 
day. But when the next day came, the people in the 
hotel were so kind to me, and so sympathetic, that I began 
to get used to my surroundings. I was too sick, however, 
to leave my bed, and I stayed in it for a week. 

I had mailed my English doctor's letter of introduction 
to Prof. Kronig, and I wondered as the days passed and 
he did not come to see me. Then one evening the head 
nurse came. It was as Mrs. Emmet had said. She an- 
swered all our questions, but she also said that I should 
have to go to Prof. Kronig, as he could not come to me. 
I was not, however, fully persuaded to go to the klinik. 
So a few evenings later the door opened and one of the 
younger doctors of the klinik, Dr. Schlimpert, came in. 
He did not bother me with questions, nor ask me when I 
thought the baby would come, nor how I felt, nor any of 
the disagreeable things doctors usually say to one in these 
circumstances. He just came over to my bed, and took 
my hand, and said, "I have come to comfort you." Two 
such friendly personalities as those of the head nurse 
and this young assistant made the klinik less formidable, 
and I readily acquiesced when he asked me to go to see 
Prof. Kronig the very next day. 

My sister and I went up to the klinik and were ushered 
into Kronig' s room. After he had examined me, he said 



MES. CECIL STEWAKT'S STOEY 187 

that I must come to the klinik that very night, as I was 
to have a breech baby and he did not trust the taxi service 
to bring me to the klinik in time if the baby started to 
come in the middle of the night. I protested, and said I 
would not think of coming to the klinik, as I felt sure I 
would have oceans of time to get there. I had had one 
baby before, and knew how long it was from the first pain 
to the baby's arrival. He threw up his hands and called 
to the head nurse to reason with me. "These American 
women are terrible/' he cried. "They always want their 
own way. You talk to her." 

The head nurse led me off and suggested that I simply 
sleep at the klinik at night, and go back to the hotel in 
the daytime. I said that if I might have my sister in the 
same room with me, I would. 

The private rooms were all full, and the head nurse 
said that we should be obliged to sleep in one of the con- 
finement rooms and she was afraid I might be nervous; 
some women were. She showed us the room. We were 
absolutely charmed with it. It was big and high-ceilinged, 
with beautiful white tiles, and surrounded along two walls 
by sterilisers and all the paraphernalia of a confinement. 
There was the little twilight lamp, there were great ceiling 
lights and lights that could be put on at the bed-foot. 
There was also a fluffy baby's crib with curtains, and a 
baby's tub. 

We came back that night about nine o'clock after we 
had had supper at the hotel. We expected there would 
be a whole staff to meet us. But instead of that we let 
ourselves into the klinik, and into our own room, and our 
own beds. No one came near us. We stayed there every 



188 AUTHENTIC TWILIGHT SLEEP 

night for three weeks, and the only member of the staff 
we saw was the head nurse, who brought new babies in 
to call on us before we were up in the morning, and after 
we had gone to our room at night. 

One day I got discouraged. My sister said that the 
only way to bring the baby was to order two horses to- 
the carriage and take the long drive up Bromberg round 
the Lorettoberg and back by way of the Schlossberg. So 
we ordered the two white horses. 

That night, at about ten o'clock, I went to bed feeling 
rather tired. At midnight I was wakened by a very sharp 
pain. I sat up in bed and rang the bell. The head nurse 
came and I said, "Schwester, I have a very bad pain." 
And she went away and came back with a hypodermic and 
gave me an injection of scopolamin-morphin. Then my 
sister was moved into the adjoining confinement room, 
which was unoccupied, and my room was got ready for 
the birth. Then I had a second injection. I began to 
feel thirsty and drowsy. And then Dr. Gauss came and 
examined me. I said, "I have an awfully bad pain." 

He said, a Yes, you have a very bad pain." And, oh, 
I was so happy when I heard him say that. It was the 
first time a doctor had ever admitted that I had a bad 
pain when I had one. Before, they had always known 
better than I had, and they had told me, "Oh, no, you 
have not got any pain at all; that is nothing; you'll have 
to have much worse pains than that." Just Dr. Gauss's 
admitting that my pain was pain made me feel comforted 
and happy. I felt at last I had found a place where 
people realised that pain was pain, even if one did not run 
round the room and scream; and they were going to try 



MKS. CECIL STEWAET'S STORY 189 

to make me comfortable and happy, and give me as pain- 
less a baby as possible ; because even then, I didn't believe 
I could have a painless child. I thought I was merely 
going to have one that was not so painful as the last one 
had been. 

I woke up the next morning about half-past seven. I 
could not see very well, because my pupils were dilated by 
the scopolamin; but in a vague sort of way I felt there 
were three chambermaids in the room, and they were wash- 
ing the floors and the furniture, and making a fearful 
racket. I thought, "This is a nice way to leave me alone 
like this; I might have the baby any minute, and not a 
doctor or nurse that I can talk to!" Because all these 
strange women spoke in dialect. And just as I was think- 
ing this, and really getting rather worked up over it, the 
door opened, and the head nurse brought in my baby. 

I sat right up in bed, and cried, "I can't believe it; it 
is a fairy tale ! It isn't true I" 

She said, "Yes, it's true" ; and I was so happy and so 
pleased, and I sat up in bed and had a wonderful break- 
fast. At ten I had a glass of milk and some biscuits; at 
eleven the white horses came round, and we sent them 
away with many lumps of sugar. At one o'clock I had 
lunch: a real German lunch, with soup, and an omelet, 
and boiled beef and cabbage, and potatoes, and roast hare, 
and carrots and peas, and a salad and dessert. I could 
hardly believe that I could have all those things to eat; 
but I had, and I ate them. I was terribly hungry and 
felt terribly well. 

Then at four o'clock I was moved to my own room 
in the private ward, and I had my sister in this room too. 



190 AUTHENTIC TWILIGHT SLEEP 

There were two white beds, one on each side of the room. 
It was a beautiful big room, not as big as the confine- 
ment room, but big compared to hospital rooms here. And 
there was a beautiful view of the mountains ; and the room 
was mostly all windows, which made it very light and 
full of sunshine; and there were fresh curtains at the 
windows, and the furniture was white and simple, and it 
looked like a beautiful room in a big hotel. 

I stayed there nearly a month, as I was taking the baths. 
I got to like it so much that I hated to leave. 

The second day after the baby was born, I got up and 
walked round my room, and washed my teeth. I can't 
explain how happy it made me to get up and wash my 
teeth, because I always hate having things done in bed, 
such as washing teeth and having my face washed. Then, 
the third day, I got up and sat up for an hour or two, 
and the fourth day I sat up all afternoon, and the fifth 
day I went out for a drive; and all the time I felt per- 
fectly well and happy and did not have anything the mat- 
ter with me at all. And I felt that a great deal of it was 
due to the fact that such wonderful care was taken of me 
by the doctors. Here in America, with my first baby, it 
seemed to me that I had always been sacrificed to that 
baby. I had to wake up in the middle of the night to 
feed it ; I had to wake up early in the morning and late 
at night when I was tired. But here in Ereiburg, between 
the hours of ten o'clock at night and ten in the morning, 
you never saw your baby. It was taken away and put in 
the nursery with the other babies, and you had a beautiful, 
long, nice sleep; and if the baby needed to be fed in the 
middle of the night it was fed by a wet nurse, or by some- 




'The second day after the baby was born I got up- 



' From 

a snapshot taken by Marguerite Tracy in the Frauenklinik, showing 
Mrs. Stewaet out of bed on the second day. 




Courtesy Miss Alice Boughton 

"Sumner," the little son of Mrs. Mark Boyd, born at Freiburg in 
January, 1914. Mrs. Boyd turned an interrruption in the course of 
work into an opportunity for intensive work of a special kind. 



MES. CECIL STEWAET'S STOEY 191 

one else in the hospital, or with a bottle of mother's milk 
that had been gotten. And then, at ten in the morning, 
the baby would be brought to you all nicely dressed and 
washed and clean ; but if it cried or annoyed you, it was 
taken out in the daytime, too, so that you always had 
your nerves at rest, and were never disturbed by the baby's 
crying, or anything. In that way I got well much faster, 
because I had sleep, and always rested, and never fretted 
about the baby or worried over it ; so that really, by the 
fifth day, I felt twice as well as I had when my first baby 
was six weeks old. 

Then, at the end of the tenth day, I began to take the 
baths prescribed for you in the klinik. These baths Dr. 
Kronig calls beauty baths, because they are supposed to 
bring back your original figure. You take them three 
times a week, for as long as you need them. I enjoyed 
them very much, and think they did me a lot of good. 

By the time the baby was a month old, my husband 
began to get impatient and cabled me to come home, so 
my sister and I started back for Paris, very reluctant to 
leave Freiburg and all the kind people. And when the 
baby was six weeks old, I sailed for America, still mar- 
velling that I had really had a painless child. 



n 

Mrs. Mark Boyd's Story 

(Reprinted here oy courtesy of "The Ladies' World") 

I came to Freiburg in the winter of 1913. Both Mrs. 
Emmet, whose first coming to Freiburg was purely acci- 
dent, and Mrs. Stewart, who came at her recommenda- 
tion, accompanied by her sister, Marguerite Tracy, were 
my personal friends. Mrs. Stewart was willing to make 
an experiment which had resulted so favourably for Mrs. 
Emmet. Miss Tracy was anxious to observe such a phe- 
nomenon as a completely painless childbirth at first hand. 
When I left New York for Freiburg, Mrs. Stewart's 
Twilight Sleep baby was already a year old, and as good 
a testimony as I needed to the harmlessness of Dammer- 
schlaf. 

During this year we had all three of us written to the 
klinik repeatedly for specific information and printed 
matter, and had been able to get no response, except as 
regarded reservation of rooms for definite patients. The 
klinik and its methods were still only known from one 
patient to another, and locally. Scientifically, it had been 
the centre of professional controversy, but of that we 
knew nothing. 

I therefore determined to use my own experience as the 

192 



MES. MAEK BOYD'S STORY 193 

basis of a definite statement to be as widely circulated as 
possible, as it would have the value of what the historians 
call a primary source, or the scientists a laboratory 
experiment. 

Miss Tracy was to meet me at Freiburg, and we felt 
sure that in a week or so we could supplement the points 
essential to a clear presentation to any woman who had any 
experience of childbirth. 

We believed that medical etiquette would be waived for 
a matter of such social value. It was not, and the few 
weeks that we had expected to spend on preparation length- 
ened into months. The doctors, kind and sympathetic 
as friends, evaded us wherever we threatened their "pro- 
fessional morality." It became a question of making 
friends amongst the Frauenklinik mothers in Freiburg, 
and amongst the professors in other departments of the 
University of Baden, who could not do too much to en- 
dorse the work of the two doctors, and who' directed us to 
the German scientific sources. 

On the literature of Dammerschlaf in medical journals 
we worked until my confinement. The confinement itself 
gave me an insight which no amount of literature could 
have furnished, both in experience and in observation. 

My social interest in the Dammerschlaf was supple- 
mented by the chance which it seemed to offer to a profes- 
sional woman who, like myself, could use the material; 
thus turning what would have been an interruption in the 
course of work into an opportunity for intensive work of 
a special kind. 

Secure in the experience of my two friends, I did not 
look forward to any ordeal, but simply to an interesting 



194 AUTHENTIC TWILIGHT SLEEP 

event. My mind has never been freer, clearer or more 
active than during that nine months. 

I left America cheerfully on the sixth month, not at 
all apprehensive of being away from my family and among 
strangers speaking a strange tongue. I had absorbed from 
my friends their sense that "in Freiburg you are safe/' 
and this conviction was strengthened when I actually 
arrived. 

My hour finally came in the dark of a midwinter morn- 
ing. As the taxicab rolled quietly along, its headlights 
the only lights burning in the most death-like hour of a 
winter day, I did not even feel the depression that comes 
from the dead cold of that hour. I was tremendously 
interested and a little excited. Indeed, after the nine 
months, it seemed more than I could grasp or hope for that 
pregnancy was now really over. 

I caught only the lower outlines of the familiar bridge 
over the Dreisam River, which runs through the city as 
one of its most prized ornaments; then the old city gate 
in Martin's Tor enclosed the taxi. Then on through the 
city along Kaiserstrasse to Albertstrasse, where the medi- 
cal schools are grouped, and the car turned in to the 
Frauenklinik. 

The greeting of the nurse, who never sleeps and never 
looks as if she needed sleep, under the lighted doorway 
of the klinik, was hospitable and most reassuring. I went 
to bed in the blue confinement room, because blue is for a 
boy, and I wanted a boy. Until afternoon there was little 
progress, but by four o'clock the pains were regular. I 
did not at once ask for my first injection of scopolamin, 
as I was unduly anxious about interrupting the labour. 



MKS. MAEK BOYD'S STOEY 195 

But at six o'clock the head nurse, allowing for American 
stoicism, persuaded me to ask for the first injection, which 
I did. 

For an hour the pains were about the same, and at the 
end of that time I had a second injection. I was tired out 
with pain, which I had suffered unnecessarily for two 
hours, and dropped dead asleep. 

It was dark by that time. The double padded doors of 
my room were closed. No one was inside with me but 
the oberschwester, and there was no light but the little 
green-shaded Dammerschlaf lamp. There was the perfect 
peace that is necessary to induce clouded consciousness. 

Several hours later I woke up. The Dammerschlaf 
lamp was still lighted, and there was a midwife in the 
room sitting apparently waiting at the foot of the bed. 
The head nurse was moving around silently, and I could 
see her, and everything else, triple, in a sort of mist, far 
off. It was like waking from a coma. I was frightened 
in a dreamy way, as if I were in a vault, alive, but put 
away like the dead. I never shall forget this strange 
impression. It was a momentary experience in real life 
of the impossible such as Poe wrote about. 

But the fact that, after a minute, really frightened me 
and filled me with despair was that the pains had stopped. 
I had a curious crafty feeling that if I kept my own coun- 
sel and let nobody know, I might fall off again into the 
real Twilight Sleep, a sleep not too heavy for the pains to 
progress. So I kept my numbed hands crossed, and only 
watched the comings and goings — more like floating they 
seemed to me — through half-closed lids. But it did no 
good. I could not drop off. Presently the head nurse 



196 AUTHENTIC TWILIGHT SLEEP 

came to the bed and caught me awake, and asked me how 
I felt. I looked at her solemnly. "Even the pains have 
stopped," I said. "I did take the scopolamin too soon." 
She laughed, stepped over to a table alongside the wall 
and brought me my baby. 

With all my preliminary studies of reports on Dammer- 
schlaf — and I had studied everything I could find about 
Twilight Sleep — I had been cheated as any of the simple- 
minded nine women out of ten are. I had wakened from 
a ten-hour labour believing that I had been caught nap- 
ping and the labour was still before me. All through the 
night — it was six o'clock in the morning when I woke — 
while my brain was sleeping, my muscles and nerves had 
been working and I had brought forth the baby from be- 
ginning to end of labour by my own efforts. Outside the 
room, my friend, Marguerite Tracy, had followed my 
progress. Inside, two doctors and three midwives had 
been with me. Towards the end I had lain masked under 
the calcium lights. I had whimpered occasionally, spoken 
ramblingly from time to time, and step by step I had fol- 
lowed the doctors' directions when difficulties arose, and 
they told me to give some strong pushes. For sleeping 
to all other ideas as the thinking brain is in Dammerschlaf , 
it is always for some unexplained reason awake to those 
connected with the work on hand. It was Miss Tracy 
outside my door who first suggested to the head nurse 
that I was biddable and could be made to work harder. 

The head nurse also asked her, laughing, where she 
had put my temperature. She had just asked me, five 
minutes after taking the thermometer from me, whether 
she had taken my temperature, and I had replied fretfully, 



MBS. MAEK BOYD'S STOBY 197 

"Daisy took it into the hall ages ago and she hasn't brought 
it back." Thns unconsciously I furnished a model irrele- 
vant answer to the memory test on which the perfect 
Dammerschlaf depends. 

On the whole, they said, I was unusually quiet and 
very sensitive to suggestion. At one point the younger 
doctor in charge of the sleep advised the forceps, as I was 
obstetrically old and stiff and structurally small. But 
Professor Kronig found the child in no danger, and let 
my "good American muscles" take their time. His longer 
experience of what can be done — or left undone — in Dam- 
merschlaf, illustrated very well the value of experience in 
using the method to perfection. 

The baby that the nurse put into my arms when I woke, 
done up in an oblong German bundle like a papoose, was 
also loud and lusty and ruddy like a papoose. I do not 
know whether he was born "short of breath" for a few 
moments as some scopolamin-morphin babies are. I knew 
beforehand, on no less a testimony than that of one of 
the chief of the early opponents of Dammerschlaf, that 
with careful use of the combined drug, this condition 
was a more or less imaginary danger, which alarms only 
the inexperienced administrator. I saw now when I held 
him in my arms in what a brisk and lively condition he 
had wakened from his doze, even if he had had one. The 
baby has never shown a tendency to be overdrowsy since. 
At first he w^as almost too alert. But of late he has devel- 
oped into a little bronze Buddha, with his brains all gone 
to stomach, as uninteresting and healthy babies should. 

This birth I have said was accomplished spontaneously, 
with no laceration, no exhaustion, no operative or other 



198 AUTHENTIC TWILIGHT SLEEP 

assistance. I had many of the structural defects that call 
ordinarily for the use of the forceps, or a long painful, 
waiting process. I had seen my sister at the same age 
and structure as myself forced to "wait/' as the obstetri- 
cians call it, for twenty-four hours of real labour pains, 
and I had seen her an invalid for several months after 
the birth. This was what waiting in consciousness meant. 
Taking my leisure at the labour in Dammerschlaf, and, 
thus preventing not only the use of the forceps, but pre- 
venting also laceration at the end, meant no exhaustion 
and no necessity to recover from what had been made as 
birth should be, a healthy physical exertion. 

My recovery was a rest, a rest indeed under constraint, 
because I wanted to be up and about. From scopolamin- 
morphin I had distended pupils and numb fingers for a 
day or so ; a thirst and a slight sweat the first night. From 
the birth I naturally had stretched muscles to restore, and 
this I did by the bed exercises, urged by the klinik, night 
and morning, which are kept up for a month or more. 
They are like the Swedish exercises of the legs and abdo- 
men, and are excellent to restore the lower part of the 
figure to the normal. Just after the exertion of labour 
the exercises are easy, but if the patient is irregular with 
them, later on, and allows her muscles to become flabby, 
she gets a realising sense of the fact that immediately 
after the birth the muscles exerted in birth are in better 
condition than after a period of inertia. 

I was up for half an hour a few hours after the birth. 
I took a motor drive on the fourth day and left the klinik 
after ten days' rest. The night of my confinement will 
always be a night dropped out of my life. 



MKS. MAEK BOYD'S STOKY 199 

"Birth is but a sleep and a forgetting/' says Words- 
worth of the life of the infant's soul before birth. And 
so it is of the infant's part in the birth process. He is 
in the ideal condition of natural amnesia. He labours, he 
struggles, he goes through all those hazards and dangers 
of birth that makes one great American obstetrician call it 
"a conflict unto death between mother and child." But 
the baby forgets each detail as soon as it happens and he 
comes out without knowledge of what he has been through. 

A prick of the needle at the apex of a pain, and birth 
can mean the same thing to the mother also ; and she, too, 
can do her part as efficiently as the painless child has 
always done his. Her equipment for her task will not 
be as it is now, inferior to her infant's. 



Ill 

Mrs. Fbancis Caemody's Stoey 

(Reprinted here oy courtesy of "The Ladies' World") 

Note: Mrs. Carmody was the first woman to go to Freiburg di- 
rectly in response to the Painless Childbirth propaganda be- 
gun in McClure's Magazine. She telephoned her physician and 
received his hearty endorsement of the Freiburg Frauenklinik 
doctors. Later, her physician visited her in the klinik at Frei- 
burg. The Freiburg method is now the routine method of 
painless birth at his hospital. 

"I came to the klinik at about five o'clock, and was 
put to bed in the birth-room ; about six o'clock I received 
the scopolamin injection. 

a The next thing I knew I woke up. I just sat right up 
in bed and looked at the clock. 

"It was seven o'clock and I realised the night had 



" 'Well/ I thought, 'I must get dressed and go back to 
the pension. Perhaps the baby will come to-morrow.' 

"Then I noticed that I felt lighter, and sat up easily, 
and my figure had changed. 

"I must have awakened before they expected me to, for 
I was all alone in the room. Luckily for me, at that 
moment the nurse came in — I was terribly excited. 

"'Baby!' I said. 'Baby!' 

" 'Yah,' said the nurse. She kept nodding her head 

200 



MRS. FEA1STCIS CARMODY'S STORY 201 

and smiling all over, and she looked blurred and queer. 
'Schoner Bub/ she said. 'Grosser Bub.' 

"Then I got desperate and made signs that, whatever 
it was, it was to be brought to me right away. 

a She went out and got him. But even then I didn't 
believe it. I thought it was somebody else's baby that they 
were trying to console me with. In fact, it wasn't till 
the whole family came in and told me we had a baby, that 
I was willing to believe he was really ours. 

"The first day the nurse said I was to get up for a 
little while. Of course, I knew it was the way, here, but 
it scared me just to think of it. I told myself I'd try, 
but I knew, of course, I would just disintegrate quietly 
on the floor. 

"But it didn't hurt me a bit. I stepped over to the 
couch, leaning on a nurse. Think of it. Not seventeen 
hours after the baby had come ! To-day I've been walking 
all around the room, and even took some dance steps ! 

"I was going out motoring this afternoon," she added. 
"But the doctor said that the wind was blowing a good 
deal and I had better wait till to-morrow. But I did so 
want to go out the second day." 

Next day Mrs. Carmody did go motoring. She called 
at the pension and gathered up another American Twi- 
light Sleep mother and we went for an hour and a half's 
drive over the hills. 

The days followed one another almost too eventfully. 

"But I feel so well/ 7 Mrs. Carmody insisted when 
remonstrated with. 

Little details of her personal experience of the Twilight 
Sleep would come out in our talk. Like other mothers, she 



202 AUTHENTIC TWILIGHT SLEEP 

came out of the sleep with her sight still slightly blurred 
by the effect of scopolamin ou the pupils, which may 
remain dilated for part of a day. 

a One of the splendid things about the Twilight Sleep," 
said Mrs. Carmody, "is that you have no after-pains." 

Another American mother also told us this. It seemed 
to her, too, that the absence of the terrible after-pains 
which often follow a rapid birth, was almost as great a 
relief as the relief of the birth-pains. 

The sixth day of Mrs. Carmody's convalescence was the 
day of the baby's christening. Probably if anyone had 
told her beforehand — that is to say, at home in America 
— that she would drive out in a landau, on the sixth day, 
to her baby's christening, her faith in that person's 
veracity, even prophetic, would have been considerably 
strained. For she is one of those sadly experienced moth- 
ers who have known what it is to be a bedridden invalid 
for six months after a confinement. 

We were interested and touched to learn that this 
American mother had, while awaiting the baby's arrival, 
and before actually having had the Twilight Sleep herself, 
written a long letter home to the woman's club of which 
she is an officer, to tell them that everything at Freiburg 
Erauenklinik was as represented in the June McClure 
article. She had wanted, as it were, to put herself on 
record as guaranteeing the facts there set down, whatever 
personal complications might attend her own case. 

The baby's father also wrote a letter — after the event 
was happily over — to a Brooklyn newspaper. 

"Mrs. Carmody," he writes, "entered the Frauenklinik here about 
6 p. m. Monday, July 13th, 1914. She was taken in charge by Drs. 



MRS. FRANCIS CARMODY'S STORY 203 

Gauss and Kronig and the head nurse. Her first injection of 
scopolamin was given about seven p. m. At one A. M. on the morning 
of the 14th, the baby was born, and for the first time she experi- 
enced a perfectly spontaneous childbirth. She slept — the Twilight 
Sleep — through it all, and her sleep continued until about seven a. m. 
on the morning of the 14th. When she awoke, she would scarcely 
believe that the looked-for event had actually happened. It is not 
the slightest exaggeration in her case to say that the confinement 
was absolutely painless. I saw both mother and child almost im- 
mediately after the birth. The baby was then crying lustily and 
Mrs. Carmody was sleeping peacefully. When she awoke in the 
morning, she was feeling as rested and fresh as if nothing unusual 
had happened during the night. 

"Under the advice of Dr. Gauss she got up the same day her 
baby was born and walked across the room to the sofa, where 
she remained for an hour, and then walked back again. On the 
day after the birth she not only got up, but began going through 
a series of exercises that were prescribed for her. On the third 
day she went automobile driving among the mountains which sur- 
round the city and was out for an hour and a half. Yesterday, 
Monday, July 20th, she was out carriage driving. Every day since 
the birth, including that day, she has eaten three substantial meals, 
including meats, vegetables, soups, desserts, etc., and she feels abso- 
lutely well. 

"I am not a physician. I am only a lawyer, but to my mind the 
secret of this activity (which is not peculiar to Mrs. Carmody's 
case, but is a common experience here) is to be found principally 
in the fact that here there are no lacerations to heal, no stitches to 
be removed, no contusions to nurse, and no deranged nervous system 
to recuperate. These things eliminated, it is not so surprising that a 
woman soon feels like getting up and going about. Of course there 
are scientific reasons given here why it is desirable to do so. 

"Now, Mrs. Carmody's case is in no wise an unusual one here. 
Such experiences are duplicated almost daily at the Frauenklinik. 
There are here now a number of American women who have had 
scopolamin at childbirth, and their experiences, when told, sound 
like the report of Mrs. Carmody's case with names and dates 
changed. Some had some pain, depending largely, it seems, on 
whether or not they refused to take the drug at the outset. Some, 
after confinement, cannot swing themselves entirely free from the 



204 AUTHENTIC TWILIGHT SLEEP 

habits contracted in former confinements of lying in bed for three 
weeks and do not begin their exercises as early as recommended. 
But making allowances for the variation of personalities, Mrs. Car- 
mody's experience is typical. There is not an American woman here 
who is not an enthusiast for the Freiburg method." 



APPENDIX I 
PAINLESS DELIVERY IN DAMMERSCHLAE 

By Bernhard Kronig 

From Deutsche Medizinische Wochenschrift 
1908 

Gentlemen : 

You have observed the method used by us for reduc- 
ing or abolishing pain in childbirth. Many of you have 
taken advantage of the opportunity of seeing mothers on 
the day after birth, out of bed. And you will have had 
the impression that by reducing the suffering we have not 
only conferred great benefit on mothers during delivery, 
but at the same time in consequence of the absence of 
suffering during delivery, the condition of the mother dur- 
ing convalescence is very much better than ordinarily. 

Will you allow me to give you a short account of our 
method of procedure and of the results which we have up 
to this time obtained. Of late the demand made of us 
obstetricians to diminish or abolish suffering during de- 
livery has become more and more emphatic. The modern 
woman on whose nervous system nowadays in the strug- 
gle for existence quite other demands are made than was 
formerly the case responds to the stimulus of severe pain 
more rapidly with nervous exhaustion and paralysis of 

205 



AUTHENTIC TWILIGHT SLEEP 

the will to carry the labour to a conclusion. The sensi- 
tiveness to pain is much greater in those who have to 
carry on hard mental work than in the case of less intelli- 
gent persons who earn their living by manual labour. As 
a consequence of this condition of nervous exhaustion, we 
see that precisely in the case of mothers of the better class 
the use of the forceps for alleviating pain where there is 
no structural need of the forceps has increased to an 
alarming extent. 

When one goes into the records of the cases of women 
of the better classes concerning the course of their previ- 
ous confinements, one is sometimes driven to the opinion 
that spontaneous birth is in their cases almost impossible. 
It is by no means unusual to hear that the forceps had 
to be used at every previous confinement. In sharp con- 
trast to this, an examination shows that neither the nature 
of the bony nor the soft passages for delivery offers 
any explanation why in every case the birth should have 
been brought to a conclusion by operation. You learn also 
very soon that it is not in the least any difficulty offered 
by the canal or a lack of muscular power in the labour 
that indicated the necessity of an operation. The for- 
ceps had been used simply and solely to shorten the pains 
of labour. 

On the occasion of the meeting of the Berlin Obstet- 
rical Society, it came to light that obstetricians practising 
in the best society of Berlin were obliged to use the for- 
ceps in nearly forty per cent, of their cases. Although it 
may be freely admitted that in the hands of a skilful 
operator the forceps is not so dangerous as in those of an 
inexperienced one, yet to you ? to whom the importance of 



APPENDIX I 207 

local susceptibility to infection has been bere so often 
pointed out, it is hardly necessary to mention that the 
chances of a favourable confinement and recovery are 
considerably diminished by any operation. The gradual 
stretching of the soft parts of the mother in spontaneous 
birth are replaced when the forceps is used, by a more or 
less abrupt tearing. The fibres of the levator, which in 
case of spontaneous birth stretch gradually, are only too 
often torn during the violent extraction with the forceps. 
In consequence of this, as Landler, Halban, and Schatz 
have shown, a disposition to prolapsus of the uterus and 
the vagina is created. Finally, the crushed tissues, often 
suffused with blood, offer good harborage to any germs 
which may find their way in. 

If you follow the lyings-in even in the best conducted 
hospitals, you will find the number of feverish cases — 
cases of temperature — is considerably higher than it is 
after spontaneous delivery. In the unfavourable external 
circumstances of ordinary practice all these injurious 
results increase. This fact finds its expression in the 
great increase of the cases of puerperal fever correspond- 
ing to the increasing frequency of operations, as shown in 
the statistics of the larger districts. It might have been 
thought that the introduction of asepsis in obstetrics and 
its extremely careful application outside the hospitals 
would have decreased the number of deaths in childbirth 
in comparison with former conditions. But so far from 
that being the case, we note unfortunately a not incon- 
siderable increase. Everyone agrees that the absence of 
a reduction in the number of cases of puerperal fever is 
chiefly caused by an enormous absolute increase in the 



208 AUTHENTIC TWILIGHT SLEEP 

number of operations and especially a huge increase in 
deliveries by the use of the forceps. In theoretical medi- 
cal instruction the "alleviating forceps" finds no place, 
but in practice the conditions are considerably different. 
The cases available for obstetric study in the hospitals 
consist for the greater part of women of no great intelli- 
gence, who earn their bread by manual labour. In pri- 
vate practice we have not infrequently to do with women 
of nervous temperaments who declare themselves inca- 
pable of enduring the pains of delivery to the end. A 
medical man often, in such cases, finds himself before the 
alternative of either ending the delivery operatively with 
the forceps or of retiring in favour of another doctor. 

If we take the trouble to sit at the bedside of women of 
some sensitiveness during the whole course of labour and 
so observe the state of their nervous system, we are com- 
pelled to admit that in their case such nervous exhaustion 
does really set in, and in consequence of their sufferings 
all power of will to hold out till the end of birth is par- 
alysed. I hardly believe that anyone who takes the oppor- 
tunity of observing a birth in the case of one of these 
women from beginning to end would afterwards agree 
with the statement that the pain of birth is a physiological 
pain which is really of advantage to the mother and must 
not be reduced. Such a statement can only be made by 
those clinicians who, having to do with too large a number 
of cases, have not taken the trouble to follow the nervous 
condition from beginning to end of labour. As indeed is 
necessary when working on a large scale at high pressure, 
they content themselves at the utmost by ascertaining oc- 
casionally how the case is going on. 



APPENDIX I 209 

When Steffen, on the occasion of a discussion about the 
reduction of pain in childbirth, gave utterance to the state- 
ment based on the experience of a large number of cases 
in the Dresden Woman's Hospital that as a matter of fact 
he had never felt any necessity for lightening the pain felt 
by a woman in childbirth, this is only to be explained by 
the fact that he was either quite callous, or that when the 
screams and groans of the woman became too loud he left 
the room. Again, acute pain at birth can in the case of 
sensitive women not rightly be termed physiological, for 
in a considerable number of cases it occasions a condition 
of severe exhaustion even after the birth. Any gynaecolo- 
gist who considers that he ought to be something more than 
merely as good an operative manipulator as possible, who 
thinks, that is, that he should observe the nervous system 
of the mother, will not infrequently note that neuras- 
thenic symptoms appear in immediate connection with 
the delivery. This is by no means surprising. One would 
rather feel astonished that long-continued exhaustion does 
not occur with the birth lesions (traumata) in persons of 
nervous disposition more often than it actually does; 
when we realise what a sensitive woman has to endure dur- 
ing a birth, even taking only mental impressions alone. 

The ground for the breakdown following birth is pre- 
pared even earlier during the period before birth by nu- 
merous bodily complaints — sickness, loss of appetite, and 
so forth. Hypochondriacal moods, it is well known, often 
preponderate in women during pregnancy. The woman 
has heard from her friends how difficult the birth of a 
child was and how great the pain ; how finally the doctor 
used the forceps and then how long puerperal fever fol- 



210 AUTHENTIC TWILIGHT SLEEP 

lowed the birth. When she herself has to give birth to a 
child, the first preliminary pains are probably stood well, 
but with their increasing frequency and violence the moral 
resistance breaks down. She feels her strength giving 
way, and does nothing but beg the doctor to use the forceps 
and put an end to her agony, and longs only for the mo- 
ment when she will be released from pain by the chloro- 
form or ether. 

If, as often enough happens in private practice, the 
forceps is used without anaesthetic, because the doctor is 
afraid to trust the continued administration of the anaes- 
thetic to an inexperienced helper, then, in addition to the 
ordinary pains of birth, the woman has the pain of the 
operation. The loss of blood, especially in the case of a 
first child, is relatively great, and bodily exhaustion is 
thus added to mental. 

It is true that robust women can stand all this without 
consequent injury to their nervous system; but it is 
equally undeniable that, if there is the slightest inclination 
to a neuropathic condition, such severe bodily and psychi- 
cal injury is the cause of a long period of exhaustion. 

Even if it were not possible, in eighty per cent, of the 
cases, to abolish the apperception of pain entirely, its 
diminution alone would be of the greatest value. 

Since the scopolamin-morphin injection put the women 
into a condition in which external impressions glide off 
them without producing any appreciable mental effect, 
women often describe their condition subsequently as fol- 
lows: they say that the craving for sleep had been so in- 
tense that they had only the one wish — to be able to sleep 
in peace, and that all that was going on round them was 



APPENDIX I 211 

absolutely indifferent to them. The deep sleep into which 
they fall during the interval between the pains and from 
which they are only temporarily awakened during the 
pains preserves also, obviously, the bodily strength. For 
this reason we are very rarely compelled to interfere 
operatively in consequence of the insufficiency of the eject- 
ing power of the muscles. 

It must of course be required of the method that it in- 
volves no danger for mother or child. We have now at 
our disposal in the Freiburg clinic the records of 1,500 
births, which took place during Dammerschlaf. This 
number is so great that the veriest sceptic cannot refuse 
to recognise the strength of the proof offered by such a 
long list. It is obvious that it was only gradually that 
the treatment attained to a certain degree of perfection, 
and that consequently the results of our last &ve hundred 
births concerning which, as they have not yet been pub- 
lished, I will give some special figures, are far better 
than those obtained in the first period during which we 
were experimenting. 

The history of the method follows: 

Several years ago Steinbiichel had already recommended 
the use of scopolamin in childbirth, since it had been used 
in surgery. I had already begun, while working in Jena, 
to perfect the method by better regulation of the doses, so 
that the pain should not 'merely be diminished but com- 
pletely abolished. In the Freiburg clinic these experi- 
ments were taken up on a larger scale. We have here 
succeeded, principally in consequence of the laborious 
observations and examinations of women in labour made 
by my assistant, Dr. Gauss, in administering scopolamin- 



212 AUTHENTIC TWILIGHT SLEEP 

morphin in such doses as you will see from the statistics. 
On the one hand neither mother nor child suffers any 
injurious effects, while on the other the consciousness of 
the mother during childbirth is so diminished that in quite 
80 per cent, of women who are treated by this method 
there is complete f orgetfulness of the course of the birth. 

The method essentially consists in reducing the mother 
to a condition in which she still has sense or nerve per- 
ception but not mental perception (apperception). Sco- 
polamin brings about a disturbance of the circulation of 
such a kind that the pain perceived by the nerves is not 
felt by the woman, or in any case it disappears so soon 
from the memory that after birth has taken place she no 
longer remembers the pain. Mansfeld a short time ago 
brought up the question whether in this method we had a 
right to speak of painless delivery. He thinks that we 
ought not to use this expression because in distinction to 
complete unconsciousness women in semi-consciousness 
awake from the sleep for a short time during the pain, give 
expression to their suffering, and then, in the interval, fall 
asleep. He maintains that the pain is nevertheless for 
the moment really perceived, and consequently is not im- 
mediately comparable with the complete abolition of pain, 
as, for instance, in inhalation narcosis. 

Practically it is at any rate comparable. Mansfeld, 
who occasionally took part in the observation of our cases, 
has also mentioned that the women, if semi-consciousness 
has been successfully superinduced, tell the doctor, over- 
joyed, when recalled to consciousness after birth, that they 
have felt nothing of the process. Their delivery was con- 
sequently, de facto, sl painless one for the patient. I 



APPENDIX I 213 

think, indeed, that if one is to enter upon this discussion, 
which could be continued indefinitely, we are entitled to 
maintain that there is no difference in principle between 
painlessness in semi-consciousness and painlessness dur- 
ing inhalation narcosis. The absence of apperception of 
pain in inhalation narcosis can be imagined also to result 
from the fact that whereas the transmission of the per- 
ception of pain to the brain is hardly disturbed, neverthe- 
less, in consequence of narcosis, the centres for the per- 
ception of pain in the brain, as is the case in semi-con- 
sciousness, are so stupefied that an apperception of pain 
does not take place. If, for example, in the case of in- 
halation narcosis, we begin the operation before complete 
unconsciousness is reached, we see that the women wince 
and even scream. If, however, we ask them about it after- 
wards, they state without hesitation that they felt no pain. 
It is consequently here also, as in the case of Dammer- 
schlaf, a disturbance of association which makes the ap- 
perception of pain impossible. 

In our method everything turns upon the administra- 
tion of the scopolamin-morphin in the right doses. Just 
as in the case of complete narcosis you must give neither 
too small nor too large a dose. If too small a dose is given, 
an insufficient effect is produced, and an overdose inter- 
feres with the action of the uterus in labour. As a test 
for the correct strength of the dose, Gauss uses an exam- 
ination of the state of consciousness. It appears to have 
been imagined that this examination is much more com- 
plicated than it in reality is, although Gauss in his very 
first study clearly explained what he intended to convey 
by the expression. The essential part of the method is 



214 AUTHENTIC TWILIGHT SLEEP 

after the administration of a certain dose of scopolamin- 
morphin by a subcutaneous injection to ascertain by put- 
ting suitable questions whether the consciousness of the 
patient is so far clouded that sense impressions received 
a short time before vanish almost directly. This testing 
of the faculty of perception is in practice much simpler 
than many people seem to think. It must be admitted that 
our method requires uninterrupted observation of the pa- 
tient. We don't deny for a moment that our procedure is 
complicated, and we believe that hardly any medical man 
would be able after only a few trials to obtain the same 
results which we can now achieve with long experience. 
In such cases a little modesty is in place. 

If our results are not at once obtained at the first at- 
tempt, it is better not at once to decry the method as a 
failure. It is decidedly preferable first to make further 
unprejudiced study. It must not be forgotten that it was 
only after a study lasting for years that we ourselves suc- 
ceeded in obtaining the present results. 

As our procedure has already been several times de- 
scribed by Gauss, I can be brief. We use two separate 
solutions — .03 per cent, in water of the scopolamin-hydro- 
bromicum, placed on the market by the firm of Merck, 
and one per cent, morphin solution. Both solutions are 
kept in a clear glass protected from light and warmth. 
If flakes form in the scopolamin solution, it is thrown 
away. We generally do not begin with the first injection 
until the pains are distressing, of at least half a minute's 
duration at regular intervals of from four to five minutes. 
We then inject as the first dose .00045 scopolamin (1.5 
c.cm. of the solution) and .01 morphin (1 c.cm.) . The first 



APPENDIX I 215 

effect generally begins to be apparent in from one-half to 
three-quarters of an hour after this injection. The women 
become tired, they doze in the intervals between pains, 
waking up during pains to give expression to pain, but 
their consciousness is not yet much clouded. About an 
hour after the first, a second injection is made, this time 
of scopolamin alone, in a quantity .00015 to .00013, ac- 
cording to the patient's condition. The testing of the 
powers of perception begins half an hour after the second 
injection. This can be carried on in a number of ways: 
i.e., the patient can be shown some object, and about half 
an hour afterwards it is shown her again and she is asked 
whether it has been shown her before. If she can still 
remember the first exhibition of the object it is a proof 
to us that the desired clouding of consciousness has not 
yet occurred, and the administration of the same dose of 
scopolamin as was employed at the second injection is 
indicated. We choose for testing the powers of observa- 
tion, preferably, such objects or events as have some con- 
nection with the process of birth and are consequently 
sufficiently well known to the patient while not being too 
striking. 

For instance, after the second injection the woman in 
labour is asked how many injections she has had. If she 
cannot remember that of half an hour before, it is a sign 
that loss of memory already exists, and that it is not nec- 
essary, for the present, to give her a new injection. Let 
us suppose that, an internal examination is now made. 
This examination can be used half an hour later as a test 
of retention or loss of memory. It certainly requires 
practice and experience to decide how best to test the con- 



216 AUTHENTIC TWILIGHT SLEEP 

dition of consciousness of particular patients in accord- 
ance with their intelligence. The hints already given may 
on this occasion suffice. No fresh injection is adminis- 
tered until the test of powers of perception shows recogni- 
tion of an object shown half an hour before. In the case 
of all but the first injection only scopolamin is given 
usually. Morphin is only added when as happens in a 
few exceptional cases slight excitement is noticeable in 
the patient. 

From what has been said, and from what you your- 
selves have observed in the delivery ward, you will have 
concluded that the proper carrying out of the method de- 
mands concentrated attention on the part of the obstetric 
staff. For the purpose of perfecting our method and for 
giving it the widest possible application to all classes of 
the population, we were able, thanks to the Grand Duke of 
Baden, to triple the obstetric staff in the delivery ward. 
I mention this intentionally because I am of the opinion 
that, especially in hospitals, with a very large number of 
cases, our procedure can be employed with any prospect 
of success only when a complete administrative reorgani- 
sation has been effected in the assignment of duty in the 
delivery ward. If, as is the case in large hospitals, the 
medical man on observation duty is relieved every twelve 
hours, the colleague who comes on duty will not be suffi- 
ciently well informed as to the condition of the various 
patients in labour. In such a case, failure is certain be- 
forehand. I consequently do not consider it the result of 
chance that it is precisely in hospitals with a smaller num- 
ber of cases that our method has been adopted. In large 
hospitals with many thousands of births a year, as in the 



APPENDIX I 217 

cases of the large hospitals of Berlin and Dresden, our 
procedure has proved a total failure. 

This is easier to understand when we remember that 
the surroundings of the patient have an importance which 
should not be underestimated for the success of the 
method. Sense impressions, loud noises, bright light, etc., 
considerably disturb the half -consciousness. When six or 
seven parturient patients lie side by side in one ward, it 
is obviously impossible to obtain an even fairly effective 
semi-consciousness. This makes itself felt even with the 
small number of patients that we have. The number of 
cases in which we obtain loss of memory (amnesia) is in 
Freiburg far smaller in those deliveries which occur in 
the general ward than in the case of patients treated in 
the private wards where they lie in a separate room pro- 
tected as far as possible from all impressions of sight and 
hearing. 

How is it with the disadvantages for mother and child 
of this method? Gauss has already in an earlier paper 
published results of our first 1,000 deliveries. In it he 
shows in detail by figures what importance the method has 
for the course of the pains. He shows also, for the period 
after birth, its importance on the general condition of 
mother and child. The results of the observations of de- 
liveries which have now increased to 1,500, have in gen- 
eral only confirmed what was then maintained on the basis 
of the statistics then available. If the drug is adminis- 
tered in the proper doses no unfavourable influence upon 
the course of the birth can be proved. 

If the writers of other papers have experienced a some- 
what large number of cases of subsequent atonic haemor- 



218 AUTHENTIC TWILIGHT SLEEP 

rhage after injection of scopolamin-morphin that is the 
result of their not having administered the drug in the 
right doses. We regularly measure the quantity of hlood 
lost in the period after birth and the result mentioned by 
Gauss has always been obtained: namely, loss of blood 
after birth does not exceed the physiological quantity. As 
far as regards the mother our results can be regarded as 
thoroughly favourable. From the 1,500 patients who have 
been delivered in Dammerschlaf, only one woman died 
during childbirth. This cannot possibly be attributed to 
scopolamin-morphin, as it was a woman with a narrow, 
funnel-shaped pelvis, whose husband refused to consent 
to cesarean section although it was absolutely imperative. 
During the discussion with him the woman's uterus rup- 
tured. As the husband even then refused consent to the 
operation, the woman bled to death. The postmortem 
showed kolporrhexis. 

Scopolamin is, it may be admitted, a drug which must 
not be used without the strictest attention to the dosing. 
All deaths which formerly took place during surgical 
operations after its injection are without exception to be 
attributed to the administration of too large a dose. There 
are, I imagine, nowadays, very few surgeons who do not 
successfully use this splendid narcotic. We have already 
for several years been using it as a preliminary to every 
chloroform-ether narcosis and to every anaesthesia of the 
spinal cord. The number of operations, which amounts 
to many thousands, has shown us, as it has shown other 
operators, that in scopolamin we possess one of the most 
humane and valuable narcotics known. 

The duration of birth is either not increased at all, or is 



APPENDIX I 219 

increased to a quite negligible extent in comparison with 
the natural duration, by the use of scopolamin-morphin. 
But even if the observation of very large numbers of cases 
should ultimately show that the duration of birth when 
this method is employed is really increased by perhaps 
half an hour, I believe that this consideration cannot pos- 
sibly be seriously allowed to outweigh the great blessing 
which we confer upon the mother by reducing the pain 
she endures. 

To form an idea of the beneficial effect of scopolamin- 
morphin injections in midwifery cases it is only neces- 
sary in the case of a woman who has had several children 
and who formerly was delivered without and now with 
anaesthesia, to inquire in the early stages of recovery how 
she feels. Such women state unanimously how much bet- 
ter they feel after the birth now that methods for reducing 
pain are used. In the whole course of my career as a 
surgeon I have never harvested such a crop of gratitude as 
I have for the use of the Dammerschlaf in deliveries. 

Fifteen hundred cases is, I think, a sufficiently large 
number to prove the safety of this method for the mother, 
provided that it is properly carried out by a trained staff. 

The opponents of the method consequently now take 
refuge in the objection that even if the procedure involves 
no danger for the mother, it is yet dangerous for the child. 
First, they maintain that the number of children who die 
during birth is greater ; and, second, that it may occasion 
injury to the bodily and mental development of the chil- 
dren later on in extra-uterine life. 

Like every other ansesthetic — morphia, chloroform, or 
ether — scopolamin also passes during the birth in minute 



220 AUTHENTIC TWILIGHT SLEEP 

quantities from the mother to the child. We are able by 
a physiological action on the eye of the frog to prove the 
presence of incredibly small quantities of scopolamin. By 
means of this reaction, Holzbach was able to show in the 
case of children born in our wards that the fresh urine 
after birth does contain scopolamin in very minute quan- 
tities. He was able, however, at the same time to prove 
that within only a few hours scopolamin was eliminated 
from the organism. The quantity of scopolamin which 
passes from mother to child during birth is generally so 
small that it exerts no ascertainable effect on the organism 
of the infant. It is only in rare cases — ten per cent, of 
births — that the children are oligopnoeic, but nothing be- 
yond simple mechanical stimulus, such as massage, is ever 
required to rapidly produce regular breathing, even if one 
does not prefer simply to wait quietly for the child to 
breathe naturally of its own accord. It was prophesied 
that in consequence of this the mortality of children dur- 
ing birth would be considerably increased, by the oligop- 
nea leading to fatal asphyxia. Here also we are able from 
the results of a large number of cases to prove the con- 
trary. First, the number of cases of oligopnea in our 
practice have very considerably decreased with the im- 
provement of the method ; at first it was 20 per cent., now 
about 10 per cent. Second, what is most important, on 
setting out statistics of the number of children who died 
during birth before and after the introduction of the sco- 
polamin method it turned out — a fact which at first aston- 
ished even ourselves — that in comparison with former 
conditions the mortality of children during birth had con- 
siderably diminished. We have had, for example, in the 



APPENDIX I 221 

last 500 deliveries under scopolamin only one child to 
mourn which died during birth ; three other children died 
within the first three days after birth. From these fig- 
ures we exclude premature births in which the child 
weighed less than 2,500 grammes. For this strikingly low 
mortality of the children during and after birth Aschoff 
has offered perhaps the right explanation: namely, that 
slight narcotisation of the respiratory organs during birth 
by extremely minute quantities of scopolamin is advan- 
tageous to the child. If we in fact conduct an autopsy of 
children who have died during or shortly after birth, we 
can frequently trace inhaled amniotic fluid, with vaginal 
epithelium and vaginal bacteria in the smallest bronchial 
tubes. Interruptions in the placental supply of oxygen to 
the child easily occur during the period of injection, es- 
pecially if the head lies low. If the child itself imme- 
diately responds to a moderate lack of oxygen by prema- 
ture respiratory movements, permanent obstruction of the 
air passages by inhalation of the amniotic fluid takes place. 
If, on the other hand, the child is slightly narcotised by 
scopolamin, it does not immediately respond to a small 
accumulation of carbonic acid in the blood by premature 
respiratory movements. The passages remain free, and 
if slight asphyxia occurs after birth a more rapid resusci- 
tation of the newborn infant is possible. These theoreti- 
cal considerations are no doubt open to dispute; the fact, 
however, remains that in a number of cases large enough 
to found some conclusions on, the mortality of children 
during and soon after birth has very considerably de- 
creased with Dammerschlaf . 

The last objection, which is still brought forward by 



222 AUTHENTIC TWILIGHT SLEEP 

opponents: namely, that the child will later on be in- 
jured by the small quantities of scopolamin passed on to 
it, can of course only with difficulty be refuted by statis- 
tics. On the basis of the births in the private wards, to- 
talling 305, where we have traced the greater number of 
the children, we are already in a position absolutely to 
refute the expectation expressed in some quarters that the 
children would display a higher death-rate in the first year 
of life. We can also definitely prove that both the physi- 
cal and mental development in these children is absolutely 
normal. I must, however, admit that members of the 
present generation will hardly be able to reply to an ob- 
jection which has recently been made by opponents who 
found themselves driven into a corner. This objection 
is that the injurious effects would show themselves in the 
mental development only at the age of between twenty and 
thirty. On this point we must allow so eminent an alien- 
ist as Hoche to speak. Eor this objection he has only the 
answer that such an assertion is simply nonsense and can 
hardly be seriously discussed. We, for our part, as gyn- 
aecologists, cannot suppress the remark that this objec- 
tion shows what unfair standards are applied when it is 
a question of opposing a new method. This is the more 
noticeable when we remember that obstetricians practis- 
ing among the better classes use the forceps in almost every 
other case, and consequently in these cases employ anaes- 
thetics, chloroform and ether, the transmission of which 
from mother to child has been proved, and when we in 
addition take into account the not inconsiderable injuries 
often inflicted on the brain of the child by the forceps. In 
no small number of cases the forceps cause subdural haem- 






APPENDIX I 223 

atoma and a pressing inward of the skull, as has been 
shown by experience in hundreds of cases. When we con- 
sider all this we are compelled to ask ourselves in amaze- 
ment why it occurs to nobody to draw attention to the fact 
that the brain action of the child is injured by these in- 
numerable forceps operations, while it is maintained that 
extremely minute quantities of scopolamin, which, as 
Holzbach has shown, disappear within only a few hours 
after birth, influence the brain action of the child up to 
quite an advanced age. 

It is not necessary, perhaps, to say that even in the pri- 
vate wards we have not used the forceps to relieve pain 
on a single occasion since the introduction of the method. 
If we may consider this last objection of our opponents, 
contrary to all experience as it is, as having been refuted, 
we may claim to have shown by our large number of cases 
that in our method we possess a procedure which, while 
in no way endangering either mother or child, has at- 
tained the end in view : namely, either the complete aboli- 
tion of the apperception of pain iu childbirth, or, at all 
events, its reduction to a minimum. 



APPENDIX H 

BIKTHS IN ARTIFICIAL DAMMERSCHLAF 

By De. Gael J. Gauss 

Archiv fur Gynakologie, Band 18, Heft 3 

1906 

Yon Steinbuchel's introduction of scopolamin-mor- 
phin into obstetric practice, which was at that time a vir- 
gin field, was a scientific event of the most far-reaching 
importance. 

Scopolamin-morphin narcosis has made its way in con- 
sequence of the priceless work of Schneiderlin and Kroff 
beginning in Freiburg, into general medical practice, and 
hitherto has found its principal applications in surgery 
and in the treatment of the insane. 

It is not necessary to follow in detail the gradual de- 
velopment of the method. I will confine myself to giving 
a sketch of the present state of the discussion as to its 
application to obstetrics and, in especial, of the experi- 
ences made with it in the Freiburg University Gynaeco- 
logical clinic. 

Up to now, only four other obstetric institutions have 
followed the example of Yon Steinbiichel's clinic at Graz 
in adopting scopolamin-morphin seminarcosis, as this 
method of employing the drug has been termed. 

224 



APPENDIX II 225 

Jena, Giessen, Budapest, and Klagenfurt have taken up 
the method as a means of alleviating suffering in birth, 
and up to the present 225 cases in all of the use of sco- 
polamin-morphin seminarcosis in confinements have been 
published. 

To these 225 cases I can add another 500 observed by 
myself in the Freiburg confinement wards. 

The object of this paper is to communicate the results 
of these experiments of my own which, as will be seen, 
differ in principle from all others hitherto published, and 
the experience I have gained from them. 

Before beginning my investigations, I endeavoured to 
gain clear ideas upon some theoretical questions connected 
with the use of scopolamin-morphin in obstetrics. 

The question is again and again asked : "Are we justi- 
fied in diminishing the sufferings of a woman in a com- 
pletely normal confinement by means of anaesthetics V 9 

I hear the answer that the suffering in confinement is 
physiological, and that it is not right to interfere unnec- 
essarily with the course of natural processes. 

But what is physiological ? And what is normal % 

It may be admitted that a mentally and physically com- 
pletely healthy woman of child-bearing age can stand the 
physiological sufferings of a normal confinement, certainly 
only by calling upon all her mental and physical strength, 
but yet without permanent injury to body or mind. But 
what about a woman having a first child at a more ad- 
vanced age, whose soft parts often offer a much stronger 
resistance to extension ? What about a patient with rick- 
ets, whose pelvis requires an especial process of birth and 
abnormal violence of the birth-pains to make spontaneous 



226 AUTHENTIC TWILIGHT SLEEP 

birth possible ? What about a patient with generally nar- 
row pelvis, in whose case in addition to the pathologically 
protracted course of the birth an increase in the physio- 
logical pressure and crushing pains, which in normal cases 
are bad enough, also occurs? . . . Does the maxim 
as to the physiological pain of a natural process apply also 
to them ? 

Is an ansemic or a neurasthenic mother of many who 
presents the country with a new citizen every year and 
nevertheless has to conduct her household with prudence 
and energy, year in, year out ... is she, I say, as 
well able to stand the physiological sufferings of an ex- 
treme exertion of bodily and mental powers as well as a 
young and vigorous woman ? 

If the medical man is allowed in these cases to reduce 
the pain, it must of course be assumed as obvious that the 
means of alleviation used are non-injurious. 

But if this demand is fulfilled, what objection can there 
be to allowing every confinement patient to participate in 
the advantages of a reduction of pain ? 

It is one of the most depressing moments which fall to 
the obstetrician's lot when he must turn away from a pa- 
tient beseeching his help without being able to afford her 
the slightest reduction of her sufferings. It is not much 
consolation for her to hear that everything is going on 
beautifully, and not a very inviting prospect to have as 
only comfort to the end of the ever-increasing tortures the 
cold maxim, "The more violent the pains, the more rapid 
the birth." 

In short, I come to the — of course entirely subjective — 
conclusion that there are no ethical objections against the 



APPENDIX II 227 

use of scopolamin-morpliiii seminarcosis for normal more 
than for abnormal births; that it is, on the contrary, a 
genuinely humane exercise of the art and science of medi- 
cine to afford the mother in every case the blessings of a 
reduction of suffering, provided of course that the scopol- 
amin-morphin seminarcosis used for the purpose can sat- 
isfy the conditions required of it. 

What qualities should be required from a narcotic 
which is to be used for spontaneous uncomplicated births % 

First as regards the mother: 

There must be a really considerable reduction of pain, 
clearly perceptible both by the patient herself and by the 
attending physician. 

Unpleasant accessory effects must either not occur at 
all or can be tolerated only if — being inseparable from 
the attaining of a sufficient degree of narcotic action : 

(a) They are not injurious to the patient, and 

(b) They are, in their intensity, not obviously dispro- 

portionate to the degree of alleviation obtained. 

In especial: 

Neither nausea nor any other appreciable feelings of 
discomfort must occur either during the course of the 
seminarcosis or as sequels to it. 

The normal progress of the birth must not be endan- 
gered by unfavourable action on 

(a) the birth-pains 

(b) the muscular contractions 

(c) the pains of the afterbirth, and 

(d) the action of the organs involved in the stoppage 

of blood loss and puerperal involution. 
As regards the child, it must not be injuriously affected 



228 AUTHENTIC TWILIGHT SLEEP 

(1) during intra-Titerine life, and 

(2) in extra-uterine life — that is, 

(a) in the initial action of the bodily functions 

(b) in the course of the next few weeks, and 

(c) in the child's later development. 

It was upon these certainly stringent conditions that I 
based the investigations undertaken by me at the sugges- 
tion of my chief, Professor Kronig, in the obstetric section 
of the Gynaecological wards of the Freiburg University. 

As the recorded experience of the use of scopolamin- 
morphin seminarcosis in obstetrics was very limited, I 
considered that I should set to work with the greatest 
caution. 

I therefore did not begin the injections until it was cer- 
tain from the stage which the birth had reached that if any 
unforeseen injury should be caused to the organism of 
either mother or child by the narcosis, the birth could at 
any time be brought about operatively without danger. 
At the same time, I at first excluded from treatment with 
seminarcosis all cases in which there were any complica- 
tions unfavourable either for mother or child: e.g., 
mothers with primary weak birth-pains, with narrow pel- 
vis, placenta proevia, and habitual irregularity of the pla- 
cental period. 

Later on, in reliance on my own favourable experiences 
of the method, I saw even in these complications no con- 
trary indication, but gave injections to practically all 
mothers who gave their consent. 

The few remaining factors that I still regard as con- 
trary indications will be mentioned later. 

Scopolamin-morphin injections have been up to the 



APPENDIX II 229 

present in the Freiburg Frauenklinik employed in nearly 
600 births. I have based my paper on the first 500 births. 

As, during the period in question, a total of 731 women 
were delivered, we see that scopolamin-morphin was ad- 
ministered in 68.3 per cent, of the cases. 

Of the 500 women, 233 (4:6.6 per cent.) were having 
their first child, and 267 (53.4 per cent.) had already had 
one or more children. 

The patients giving birth to the first child ranged in 
age from nineteen to thirty-five, the average age being 
twenty-four. The others ranged from nineteen to forty- 
five, with an average of thirty. 

Of the 500 births, 483 were head presentations, 6 face 
presentations, 4 breech presentations, and 7 cross-presen- 
tations. 

Amongst these cases, the following complications pre- 
sented themselves : 

Narrow pelvis 40 

Hydramnios 5 

Prolapsed cord 4 

Nephritis 2 

Eclampsia 3 

Partial premature detachment of placenta 2 

Placenta praevia 3 

Habitual haemorrhage after birth 1 

Habitual adherence of placenta 1 

Rupture of the cervix 2 

Uterus myomatosis 2 

Vitium cordis 1 

Fever during birth 15 

Pneumonia 1 

Peritonitis 1 



230 AUTHENTIC TWILIGHT SLEEP 

As to the frequency of operation, the following may be 
stated : 

Of the 483 head presentations there were 434 spon- 
taneous births. In 49 cases the forceps was used — in 14 
because absolutely necessary for the mother, in 22 because 
necessary for the child, and in 14 in consequence of a 
relative indication (retarded rotation or ejective action). 
Subcutaneous hebotomy was performed 4 times, the classi- 
cal caesarean section 1, and vaginal csesarean section 1; 
foot rotation in a case of head presentation was carried 
out 4 times — once on account of placenta prsevia, once on 
account of prolapsed cord, and twice (twins) on account 
of high fever in the mother. 

Eotation was carried out in 8 cases of cross-presenta- 
tion — 3 times to head on account of the cross-position, 
twice to a foot presentation after failure to produce head 
presentation, 3 times on account of prolapsed cord.* 

In addition to the individual sensitiveness of the pa- 
tient, the time that has elapsed since the injection, and 
the dose employed, have of course a great effect on the 
nature of the action of scopolamin-morphin. 

The first sign of the action of the drug is pronounced 
weariness, which very soon passes into a peaceful sleep 
occupying the whole of the pauses between the pains, but 
out of which the patients are startled by every pain. 

The suffering during the pains is indeed at this stage 

*42 minor operations were performed, including 30 stitchings 
of lacerations; also 7 operations in placental period. 

Description of preparation of the drug is omitted since prepara- 
tion makes it unnecessary. 



APPENDIX II 231 

clearly perceived as such, but is considerably reduced : in 
fact, and — at least in the case of critical and intelligent 
people — also subjectively. At this stage I have often 
heard such spontaneous remarks as, "How nice (sic) it is 
to be conscious of the pains but to feel no suffering !" 

Gradually further signs of the commencing action of 
the drug occur: thirst, with a dry feeling in the mouth 
and throat, flushing of the face, occasionally slight twitch- 
ing in the flexor muscles of the fingers, and sometimes a 
certain degree of motor restlessness. After longer action 
and sufficient dose, the sleep becomes deeper, so that even 
during the pains the patients do not become fully awake, 
and the only signs of the pains are painful contortion of 
the expression muscles of the face, slight groaning. 

But consciousness is at this stage fully retained. The 
patient can remember exactly anything done to her. It 
is this stage that those who have hitherto championed the 
scopolamin-morphin seminarcosis regard as the goal to be 
aimed at. 

But in consequence of the results of my cautiously made 
investigations I have gone further. 

Only a slight deepening of the seminarcosis is sufficient 
so to cloud the consciousness without entirely abolishing 
it that the final result of a skilfully graduated dose is a 
kind of artificial fuddled condition the principal charac- 
teristic of which is a complete amnesia extending over the 
whole process of birth. 

I said to myself it is undoubtedly a great advance to 
be able to diminish the suffering of the mother. But in 
spite of this every patient would have the impression in 
consequence of the continuous increase in the intensity 



232 AUTHENTIC TWILIGHT SLEEP 

of the pains up to the end of the birth that her sufferings, 
in spite of the injection, also increased. The injection 
would be a great advantage to the patient, but one the 
value and importance of which for the reasons mentioned 
above would often be greatly underestimated by her, espe- 
cially in the case of inexperienced mothers at the birth 
of the first child. 

As, however, a slight increase in the dose injected is 
sufficient to produce total loss of memory of the suffer- 
ings during birth, and of all occurrences taking place 
while the dose remains effective, there seemed to me to be 
no doubt that the object of the seminarcosis must be to 
put the patient into that kind of Dammerzustand which 
she afterwards is unable to remember. 

It is this point which distinguishes my investigations 
and results in principle from those of other obstetricians 
who were all satisfied with having reached only painless- 
ness, or, to speak more accurately, a sort of subpainless- 
ness. 

After the first groping attempts which as they only 
aimed at a hypalgesia confined themselves to the limits of 
the investigations carried out in other clinics, I injected 
such doses that the object aimed at — complete loss of mem- 
ory of the birth — was as far as possible reached. 

This object could of course not be obtained in all cases. 
In the first place a number of patients arrived so late for 
treatment that the injection could not take effect until 
the birth was practically over; of such cases there were 
28 — that is, 5.6 per cent, amongst the 500 recorded births. 
The only effect of the injection was a sound, peaceful sleep 



APPENDIX II 233 

following the birth and often also a clouding of the con- 
sciousness, which only set in after birth. 

A second group of patients showed indeed a clear and 
objectively observed diminution of pain. But the women 
themselves spoke in the most contradictory manner, cor- 
responding to their various degrees of judgment and in- 
telligence as to the extent of the effect of injection. 

This group included 91 of my 500 cases (18.2 per 
cent.). In their case the dose given was not sufficient to 
produce a profound effect in the time at our disposal, be- 
cause either this time itself was very short, or because the 
patients turned out to be somewhat refractory to a dose 
that on the average had proved sufficient. 

The third group — 381 in number (76.2 per cent.) — of 
my cases consists of those patients in whose case the de-» 
sired effect was, at all events for a part of the time, fully 
attained. 

In their case, as in that of the others, a clear reduction 
of suffering and sleepiness first appeared; but on admin- 
istering a sufficient quantity of the drug in making the 
injections, concerning which I shall go later into more 
detail, the patients fell into a kind of Dammerzustand in 
which sensory impressions were no longer permanently 
recorded, and as to which, consequently, according to its 
depth and effectiveness more or less compete amnesia 
exists. 

The patients react in a very varying manner whilst in 
this condition. 

The majority of the patients impress one as being in- 
deed sleepy, but otherwise quite normal. Every pain is 
accompanied by clearly perceptible if often only slight 



234 AUTHENTIC TWILIGHT SLEEP 

expressions of suffering. The pains and the accompany- 
ing sufferings are referred to and felt clearly as such. 
Every question is perhaps sleepily but nevertheless clearly 
answered. 

In this stage nothing beyond the very pronounced weari- 
ness of the patient strikes the unprejudiced layman or 
even a medical man who was unaware that an injection 
had been given. So much the more astonishing is it sub- 
sequently to learn that the patient whom one believed to 
be completely conscious has, after the birth, not the slight- 
est idea of what she has just gone through, or of the 
conversation held with her. 

The term seminarcosis does not do justice to the pe- 
culiarity of this most curious condition of consciousness, 
which has much more resemblance to the waking condition 
than to narcotic trance. The patient is in a stage of artifi- 
cial sleep from which she may wake or be awakened at 
any moment for a short time ; at the same time, however, 
during the whole period of the action of the injections 
she displays the amnesia characteristic of this clouded 
mental condition. 

Taking into consideration these two principal symptoms 
of this intentionally produced and peculiar condition, and 
also the difference in principle between it and the condi- 
tions of seminarcosis hitherto reported on, I consider 
myself entitled to speak of my method as an artificial 
Dammerschlaf. 

If it is perhaps intelligible that the patient should no 
longer quite clearly remember events further in the past, 
it is yet sometimes in the highest degree striking how 
little remains in the memory during the reign of this arti- 



APPENDIX II 235 

ficial state of clouded intelligence of the most important 
occurrences in the immediate past ; for example, the birth 
which has just taken place. It may perhaps be of inter- 
est if I here give a few examples of daily experiences in 
our delivery ward. 

I have often seen the patient, after the last and suc- 
cessful ejection pain, sink back on the pillows with the 
sigh of relief, "Thank God, that's all over!" She had 
consequently, at the moment, a clear perception of the 
birth that had taken place, and took also the greatest in- 
terest in the child, its sex, state of health, and crying. If, 
however, she were asked about ten or twenty minutes later 
some such question as when her child was coming, she 
would reply that she didn't know; that it wouldn't be 
much longer, or would give some similar answer which 
clearly showed that the fact of the birth having taken 
place, although it had been certainly perceived, had yet 
not been included in the storehouse of memory. In other 
words, that — as the alienists say — it had been perceived 
but not apperceived. 

At this stage it is my custom to show the mother her 
child. At this dramatically effective moment the mothers 
divide themselves into two groups. 

Those of the one group, obviously those sceptically in- 
clined, will not hear of the suggestion that they have borne 
a child without pain 7 and are either offended or amused. 
Some of them declare the child to be ugly, and therefore 
probably the property of the occupant of the next bed. 

The others, in consequence of our having previously 
discussed painless birth with them, are more predisposed 
to belief although with the utmost astonishment they re- 



236 AUTHENTIC TWILIGHT SLEEP 

joice that they have already got through the birth. It is, 
however, quite easy subsequently to suggest to them that a 
joke has been played on them, if indeed they have not 
already after a quarter of an hour entirely forgotten that 
the child had been showed to them. 

A patient of this type presented her own child to her 
indignant and horrified husband as being that of her 
neighbour, at the same time expressing the greatest long- 
ing that the child she was expecting should also be a boy. 

I felt able in this case to promise the woman a boy with 
the greatest confidence. 

Another patient, when asked whether her child had 
already arrived, replied with a superior smile that she 
could feel that it was still within, and, in addition, per- 
ceived clearly the movements of the child. Not until a 
heavy bag of sand had been removed from her body did 
she finally allow herself to be convinced that the delivery 
had already taken place. 

A whole series of patients were removed from the de- 
livery ward in the conviction that they were being taken 
back because the birth pains were too feeble. 

The patient who had just been delivered and who once 
before, four weeks before her baby was due, had had birth 
pains and been taken to the delivery ward but after that 
had been again up and about for a month, absolutely re- 
fused, from fear of the ridicule of the other women in her 
ward, to allow herself to be once more carried out of the 
delivery room without having attained her end. Others 
again considered the fact that they were carried back the 
best guarantee that the birth must have taken place; and 
as to the identity of the children that were given to them 



APPENDIX II 237 

relied entirely upon the honesty and uprightness of the 
attendants. Under such circumstances the well-known 
Kwilecki case would have heen unnecessary. 

A section, but only a small section, of patients treated 
with scopolamin-morphin display a quite different picture. 
They impress the spectator most clearly as having a very 
clouded or entirely inhibited consciousness, and this in 
one of two possible ways. 

Either they sink into a deep sleep in which they, when 
addressed, either do not respond at all or do so only 
sleepily and imperfectly. 

Or, the effect of the drug displays itself in an exactly 
contrary manner by a more or less intense condition of 
excitement, so that it is precisely the watching of these 
patients that gives the medical man and the assistants the 
greatest trouble. Such women in some cases only exhib- 
ited an increased motor restlessness which found expres- 
sion in motiveless grasping movements, or in — sometimes 
violently — insisting on getting out of bed. In most cases 
the necessity of going to the W. C. was given as the 
reason. In some of these cases continual holding or bind- 
ing the hands was absolutely indispensable. In all, I have 
observed such conditions about seven times. 

In a few cases clear symptoms of delusions of guilt 
were observed in the course of the birth. Three of the 
women declared their agony of suffering to be the natural 
consequences of a more or less sensational slip from virtue 
of which they imagined themselves to be accused. 

Not one of them remembered these events after the 
birth. 

I have hitherto found no clear explanation for this 



238 AUTHENTIC TWILIGHT SLEEP 

effect of scopolamin-morphin, which has also been occa- 
sionally observed by alienists, the number of observed 
cases being too small. Perhaps the most probable solu- 
tion is that this undesired effect of the injection is simply 
the result of a large overdose in the case of a specially 
susceptible patient for whom a smaller quantity would 
have sufficed. Corresponding to the special effects of 
morphin and of scopolamin alone to be mentioned in the 
section on dosage, one would have to attribute the comatose 
type of overdosing effect to an excess of morphin, and 
the excitement to an excess of scopolamin. This view is 
supported by the fact that I observed the first form prin- 
cipally during the period in which large doses of morphin 
were used, and the latter form only since the morphin dose 
has been reduced. 

I will conclude my observations of the narcotic action 
of the scopolamin-morphin injections with the following 
resume : 

The pain-reducing and soporific effect when the drug 
has acted for only a short time is extremely pleasant to 
the patients, so that they often describe the condition pro- 
duced, in so many words, as "comfortable and pleasant," 
and generally ask for a new injection, of their own accord, 
when the effect wears off. 

The Dammerschlaf of the patient which begins when 
the action of the drug is more intense and in which she 
experiences a clouding of the consciousness but no depri- 
vation of consciousness is, however, absolutely ideal. One 
special peculiarity of the Dammerschlaf — the amnesia, 
which is generally complete — is especially pleasant and 
desirable, and that on various grounds. 



APPENDIX II 239 

The fact that there is absolutely no memory of the ex- 
ertions which towards the end of the birth become more 
and more frequent and intense does away with that con- 
dition of mental exhaustion that we so frequently observe 
in protracted births. By this I mean a condition in which 
birth-pains occur, but the patient in consequence of her 
mental and physical exhaustion is not in a condition to 
take effective advantage of them by active co-operation. 

It is obvious that sensitive and nervous individuals are 
most liable to this undesirable interference with the prog- 
ress of birth which is so often observed and is known as 
secondary insufficiency of birth-pains. 

It is precisely in the case of patients who are already in 
a highly excited condition when they come to be treated, 
and especially in the case of those who have previously 
had to endure fruitless attempts to deliver them, that the 
effect of the injections is so beneficial that under such 
circumstances I should be sorry to have to do without 
them. 

In conclusion I believe I am entitled to ascribe yet an- 
other quite special advantage to the amnesia obtained by 
means of scopolamin-morphin Dammerschlaf. It is well 
known how seriously the nervous system of a woman is 
or may be affected by a difficult birth which demands the 
exertion of the last remnant of her mental and bodily 
strength, and that such a birth, if a corresponding ten- 
dency already exists, might possibly give rise to more or 
less severe nervous exhaustion in which the memory of 
the terrors of child-bearing, and the fear of a repetition 
of them may reduce the woman's capacity for work and 
embitter her whole life. The army of suffering women 



240 AUTHENTIC TWILIGHT SLEEP 

who, although they exhibit no signs of definite disease of 
the organs of generation, yet consult the gynaecologist be- 
cause they attribute the general nervous complaints caused 
by the memories of child-bearing to this region, shows 
emphatically how extremely injurious to the nervous sys- 
tem a birth may be in an organism disposed to nervous 
weakness. 

Now there can be no possible doubt that birth loses the 
character of an injurious trauma to the same extent as the 
physical suffering and the mentally injurious impressions 
are reduced or even completely abolished. 

It is therefore not only easily conceivable but even very 
likely that a woman with a predisposition to nervous trou- 
bles — nervous attacks caused by overexertion, neuras- 
thenia, hysteria, etc. — might be spared the undesirable 
sequelae of childbirth to which she might otherwise easily 
have fallen a victim, merely by blotting out her recollec- 
tion of it. 

Although considerations of this kind are of the nature 
of theories, which it is difficult to rigidly prove, yet one 
is certainly to some extent justified in drawing conclusions 
from the degree of exhaustion exhibited by the patient on 
leaving the delivery room as to how far she has been tried 
by the birth. How many women feel the effects for days, 
and cannot get rid of the exhaustion and lassitude which 
remain! It is perhaps due to the avoidance of this state 
of exhaustion that the women delivered under the influ- 
ence of scopolamin-morphin almost always pass the very 
first night after the birth in a deep and refreshing sleep 
which many a woman, delivered in the ordinary manner, 
cannot obtain although greatly in need of it. 



APPENDIX II 241 

The statement so often made to me that a patient had 
never been so comfortable after a birth, the repeatedly 
made observation that the women in consequence of their 
loss of memory believed that they had been in labour for 
only about a third of the real time — these two facts can 
only confirm me in the belief that in the scopolamin-mor- 
phin Dammerschlaf we have an efficacious means of doing 
away with the nervous sequelae of childbirth. 

The question whether the scopolamin-morphin Dammer- 
schlaf suffices for the carrying out of obstetric operations 
is of practical importance. That the answer to this ques- 
tion is in the negative will, considering the description 
already given of the action of the injections, excite no 
great surprise. For obstetric operations a complete re- 
laxation of the walls of the abdomen and immobility of 
the patient are in most cases necessary, and these can only 
be obtained to an approximately sufficient degree if the 
depth of the Dammerschlaf has far overstepped the 
boundary separating it from more or less deep genuine 
narcosis. In a few isolated cases I have been able under 
such circumstances to use the forceps and to make a peri- 
neal suture or a hebotomy without needing the use of an- 
other anaesthetic. As, however, for the sake of both mother 
and child, a scopolamin-morphin narcosis should be 
avoided, it is obviously necessary to have recourse to 
another narcotic if an operation has to be made. 

For this purpose, we use the most various methods of 
obtaining narcosis in the particular cases for which they 
appear most suitable. 

We have frequently used ether-chloroform-oxygen, 
ether-chloroform, laughing gas, and ethel-chloride in con- 



242 AUTHENTIC TWILIGHT SLEEP 

junction with scopolamin-morphin to our complete satis- 
faction and without injurious results to either mother or 
child. A special advantage of the Dammerschlaf for the 
use of the anaesthetic mentioned is that neither the strug- 
gling on the part of the patient due to sensations of suffo- 
cation nor the stage of excitement occur at all in the ma- 
jority of cases. 

We have recently experimented extensively with Bier's 
lumbal anaesthesia produced by means of stovain alypin 
and novocain suprarenin in connection with the Dammer- 
schlaf, and have not observed any unfavourable results 
arising from the combined use of both narcotics. In this 
case also . the scopolamin-morphin Dammerschlaf proved 
its usefulness as a method which very considerably reduces 
the sensitiveness to stimulation and which consequently 
has enabled the medulla narcosis to be employed to a much 
greater extent. 

In what quantity and how must scopolamin-morphin 
be, then, introduced into the body to produce Dammer- 
schlaf? 

The dosage is naturally entirely different from that em- 
ployed in surgery. In the first place, a woman in child- 
birth is in any case much more susceptible than usual to 
all narcotics, so that much smaller doses would suffice to 
produce the effect desired by the surgeon: viz., complete 
narcosis. 

In the second place, it is far from being our intention to 
attain a deep narcosis. We must even, on the contrary, 
avoid this, as we insist on the condition that the groups of 
muscles which play the most important part in the work 
of birth, those which together produce the straining action, 



APPENDIX II 243 

should retain their effective action, and that not only as 
regards their voluntary but also their involuntary action. 

The object to be attained by the use of the scopolamin- 
morphin Dammerschlaf in obstetrics is, in fact, nothing 
beyond a reduction of suffering, and that slight degree of 
clouding of the consciousness in which impressions are 
perceived indeed by the patient, but not apperceived. It 
is obvious that the dosage employed by me for the injec- 
tions during the period embraced by the 500 births has 
not remained the same as that at first employed. As I of 
course in the first attempts went to work very cautiously, 
I had frequent failures with the small doses initially em- 
ployed. Encouraged by the first successes, but not yet 
satisfied with the results, I then tried larger doses, and 
found that in most cases the stage of Dammerschlaf could 
be reached and that in almost as short a time as one liked. 
But that as the price of a too large dose in proportion to 
the time unpleasant accessory symptoms have to be put 
up with which as a matter of fact should be avoided. Fur- 
ther experiments served to ascertain whether simply the 
quantity of scopolamin-morphin solution used in a given 
time, or whether an excess of one or other of the compo- 
nents of the mixture, was responsible for these undesirable 
accompaniments. By systematically carried out series of 
dosings I came to the conclusion that in most cases the 
undesirable concomitants were due to a too large dose of 
morphin. "When the quantity of morphin was reduced, 
they disappeared, whilst the narcotic action of the injec- 
tion was in no way reduced. 

The conclusive test was a series with an increased quan- 
tity of morphin and a series with scopolamin alone ; whilst 



244 AUTHENTIC TWILIGHT SLEEP 

in the first cases the concomitants were still more pro- 
nounced than before, they were only observed in the sec- 
ond series when the dose necessary for prolonged sleep was 
considerably exceeded. 

In spite of this, the use of scopolamin alone did not ap- 
pear advisable, since as had been already observed by 
alienists and pharmacologists it occasioned in many per- 
sons a condition of excitement. It seemed best, therefore, 
to use in addition to the scopolamin a sufficient but not 
too large quantity of morphin, so that the unpleasant at- 
tendant effects, whether of morphin or of scopolamin, can 
be avoided without any diminution of the narcotic action. 

It is not possible to discuss here in detail the various 
series of experiments on dosage upon which I have based 
my conclusions. Anyone who wishes to check my results 
I will gladly allow to see the innumerable series of lists 
and tables drawn up from various points of view. 

For the above reasons I thought it advisable to use two 
separate solutions prepared by a pharmaceutical chemist: 
a .03 per cent, solution in sterile distilled water of the 
crystalline scopolaminum hydrobromicum sold by Merck, 
and a 1 per cent, morphin solution. I continue to use 
both until cloudiness and the formation of flakes show 
that they are going bad. I have ascertained by experi- 
ment that the solutions have remained effective for over a 
year ; an addition of carbolic acid did not prevent the solu- 
tion from deteriorating. 

The opinion that the very varying action of the drug is 
due to instability in its chemical constitution caused by 
some unknown factor must be regarded as erroneous. I 
was able to prove that one and the same solutions produced 



APPENDIX II 245 

effects differing greatly in degree in the case of different 
persons on the same occasion and also in the same person 
on different occasions. 

We are therefore compelled to assume a variation in the 
susceptibility of various constitutions for the action of 
scopolamin-morphin and also the variation in the suscep- 
tibility of the same person at different times — a concep- 
tion which in itself is in no way improbable. 

I have been able to ascertain only partially on what fac- 
tors this varying susceptibility depends. 

To a small degree the weight of the person, if constant 
for considerable time, has an influence: tall, massively 
built persons usually require a larger dose than short and 
slender ones. 

Conversely, all organisms which have been pulled down 
by illness, exhaustion, or ansemia, react to scopolamin- 
morphin to a greater extent. In the case of such patients, 
therefore, one must begin with smaller doses. The use of 
alcohol appears to be without any considerable influence 
on the success of the injection. At all events, natives of 
Baden who are accustomed to indulge in alcohol in very 
considerable quantities display no striking resistance to 
the action of the drug. 

This varying degree of reaction in different individuals 
which it is hardly possible to ascertain with certainty be- 
forehand leads to the conclusion that the precaution should 
be taken of making the first injection rather a little too 
scanty than too generous. 

I generally begin with a dose of .00045 to .0006 scopol. 
hydrobromic. and .01 morph. mur., which in the case of 
persons of average constitution and susceptibility gener- 



246 AUTHENTIC TWILIGHT SLEEP 

ally develops its full effect in from forty-five minutes to 
three hours. If the desired effect is not obtained, a sec- 
ond injection of .0015 to .0003 scopol. hydrobromic. with- 
out morphin is then given, which almost always takes 
effect in about a quarter to half an hour. When signs 
appear that the action is passing off — that is, in general, 
after from two to four hours — another injection suited to 
the special circumstances of the patient is necessary. A 
repetition of the second dose in general suffices, which is 
only strengthened by the addition of .005 morph. mur. if 
the patient, whether unintentionally or at the will of the 
medical man, has been again completely conscious for a 
considerable time. 

It is my experience that a Dammerschlaf induced in the 
manner described above can be maintained for several 
days without injurious consequences, especially as with 
reasonable practice and care the danger of overdoses is 
easily avoidable. 

The period of time elapsing between the first injection 
and the birth of the child in Dammerschlaf was : 

Not over half an hour 31 cases 

« « 1 " 38 " 

2 hours 64 " 

« « 3 " 86 " 

« « 5 " 78 " 

« « 7 " 64 " 

« " 10 " 66 " 

« " 15 " 42 " 

" « 20 " 23 " 

" « 25 " 8 " 

" " 30 " 3 " 

" " 35 " 3 " 



APPENDIX II 247 

Not over 40 hours 3 cases 

" " 50 " 1 case 

" " 57 " 1 " 

In 13 cases the injections were for various reasons in- 
terrupted. These were mostly births during the first pe- 
riod of the investigation, when in consequence of insuffi- 
cient certainty in judging of the eventualities occasioned 
by the action of the scopolamin-morphin one abstained 
from further injections if any complications appeared. 
More recently the only grounds on which the injections 
were interrupted were the contrary indications to be con- 
sidered more in detail below. 

The largest total doses administered to an individual 
patient amounted to .0031 scopol. plus .0475 morph. over 
a period of 48 hrs. in one case; of .00315 scopol. plus .025 
morph. in 47 hrs. in a second case; and of .0036 scopol. 
alone in 36 hours in a third case. 

The longest time in which a patient was under the ac- 
tion of the drug was 48 hours, in the case of a patient for 
whom .0031 scopol. plus .0475 morph. were necessary to 
maintain the Dammerschlaf.* 

When we remember that many surgeons often admin- 
ister such quantities of scopolamin-morphin in three doses 
within four hours to obtain general narcosis, we certainly 
can't raise much objection to the very modest claims of 

* Since writing this paper I have even kept a patient under 
Dammerschlaf for more than 57 hrs. for which a total of .00375 
scopol. + -03 morph. was necessary. She was 36 years old and hav- 
ing a first child. The soft parts were rigid, there was premature 
bursting of the membrane, and it was a very large child. Mother 
and child are doing well. The former had no idea how the birth 
had taken place, the child was born active and lusty. (C. G.) 



248 AUTHENTIC TWILIGHT SLEEP 

the obstetrician. At all events, it is not justifiable to 
bring those serious accusations against the obstetric doses 
which recently, especially by French writers, have been 
brought against the large surgical doses. And precisely 
on account of the absolutely different system of dosing, 
any parallel between the means of application of the two 
methods must be energetically repudiated. 

The problem of maintaining the uninterrupted action 
of scopolamin-morphin is more difficult than that of in- 
ducing it. The most obvious idea would be to deduce the 
narcotic action from the signs of pain shown by the pa- 
tient. But these exhibitions of pain only cease entirely 
in a small proportion of the cases. And besides this they 
also increase physiologically even in artificial Dammer- 
schlaf towards the end of the birth, so that for these rea- 
sons they afford no reliable clue to the extent to which the 
consciousness is clouded. 

In the search for better criteria, I have systematically 
examined the behaviour of most of the known reflexes as 
also of the psychic functions under the influence of 
scopolamin-morphin and have obtained the following 
results : 

Whilst the mucous membrane reflexes experience no 
alteration worth mentioning, the skin, tendon, periosteal 
reflexes are markedly increased at a fairly early stage, but 
I have been able only to a very slight degree to discover a 
regularity which could be employed for my purpose. 

According to Link's investigations, which in part were 
carried out on patients in childbirth in our institution, the 
Babinski phenomenon is a sign of the beginning of the 
action of scopolamin which appears very early. The 



APPENDIX II 249 

shortest time in which it appeared was in a few minutes 
after the injection of .0012 scopol. hydrobrom. ; the small- 
est dose after which it was observed consisted of .0004 
scopol. hydrobrom., the simultaneously injected morphin 
being without effect in this respect. As patients react 
to scopolamin-morphin in extremely different ways, it 
would be all the same important to be able to ascertain by 
means of Babinski's reflex that the initial effect of sco- 
polamin consisting of the functional cutting out of action 
of the cortex of the cerebrum was already taking place. 

The pupillary reflexes take place in a perfectly normal 
manner with the exception of the dilatation due to pain. 

The sensibility is not affected to any considerable ex- 
tent; co-ordination, on the contrary, displays a more 
marked influence, and in conclusion, as regards the psychi- 
cal aspect, the intelligence only suffers an apparent dimi- 
nution due to the drowsiness. Whilst the memory works 
well, the increasing clouding of the consciousness is ac- 
companied by an ever-increasing reduction of the capacity 
of observation. Of all these observations only the testing 
of the reaction of the pupils to pain, of locomotor co-ordi- 
nation, and of the capacity for observation appeared to 
me to be likely to be of practical use. I shall therefore 
devote particular attention to that. 

The dilatation of the pupils in response to bodily pain 
takes place, as I was able regularly to ascertain, also in 
response to a birth-pain, and is greater the more acutely 
the patient is conscious of the sensation of pain. It is 
consequently justifiable to draw the converse conclusion 
that the stronger the narcotic effect the less will be the 
dilatation due to pain in the course of a birth-pang ; and in 



250 AUTHENTIC TWILIGHT SLEEP 

fact this is so in a great number of cases. But in others 
the effect is absent, as it frequently is in the case of pa- 
tients whose pupils have been greatly dilated in conse- 
quence of the preponderation of the action of the sco- 
polamin. 

The absence of this reflex cannot therefore up to the 
present be regarded as an absolute indication of the extent 
to which the consciousness has lapsed. 

A second and in my opinion not unimportant criterion 
is the negative results of co-ordination tests, and espe- 
cially of locomotor co-ordination test. 

Of the various ways of testing locomotor co-ordination, 
I generally use the one which consists in asking the patient 
to put the tips of her forefingers quickly together whilst 
keeping her eyes closed. 

The influence of a scopolamin-morphin injection on the 
co-ordination of muscular action is exerted promptly. As 
the Dammerschlaf gradually begins, the locomotor co- 
ordination becomes worse and worse, and when the nar- 
cotic action has reached its highest point it is almost en- 
tirely absent. 

It is easily intelligible that the observation of this indi- 
cation is not an ideal criterion of the depth of the narcosis, 
either. In order to introduce as little of the narcotic into 
the body as possible, the Dammerschlaf should be as light 
as it can possibly be without ceasing to be fully efficacious. 
But it is exactly for this debatable ground between sleep 
and waking that to judge the amount of clouding of the 
consciousness from the extent of the accompanying loco- 
motor ataxia is by no means easy and the test often am- 



APPENDIX II 251 

biguous. I needed consequently some other absolutely 
certain test. 

After trying all kinds of things, I believe I have discov- 
ered a test such as I need, one that if certain rules are 
observed never fails. 

I was put upon the right track by the following consid- 
erations derived from views current amongst alienists: 

The stage of scopolamin-morphin action that we wish to 
reach is a kind of condition of clouded consciousness — that 
is, a derangement of the consciousness. What we term 
consciousness is the sum of the simultaneous mental proc- 
esses into which internal and external stimuli are trans- 
formed. Derangements of the consciousness are conse- 
quently pathological deviations from the regular course of 
these mental processes, which can exhibit various degrees 
of clearness according to the magnitude of the liminal 
value. A clouding of the consciousness in which the 
clearness of consciousness falls below a certain standard, 
we term "Dammerzustand" (a condition of clouded con- 
sciousness). 

Owing to the fact that the associative bridges between 
the consciousness during the term of this condition which 
we have just defined, and that of the waking condition, are 
for the most part broken down, there is a more or less well- 
marked defectiveness of memory for events occurring dur- 
ing the befogged condition ; the same kind of defect which 
we also observe in the amnesia occurring after scopolamin- 
morphin injection. 

Amnesia in general is a derangement of the memory 
which may take either of two completely different forms. 

For we distinguish between weakness of memory which 



252 AUTHENTIC TWILIGHT SLEEP 

consists in a diminution or loss of the capacity for remem- 
bering past impressions and the derangement of perception 
which is characterised by limitation of the formation of 
new memory pictures and images. In the amnesia pro- 
duced by scopolamin-morphin the retention of already 
formed memory pictures and concepts is not affected but 
only the formation of new ones. 

It must consequently be also conversely possible by test- 
ing the capacity of perception to arrive at conclusions as 
to the subsequently appearing amnesia and so as to the 
intensity of the action of the scopolamin-morphin at the 
moment. 

My at first not very sanguine expectations were, how- 
ever, confirmed by the favourable results of the experi- 
ments. The so-called scopolamin visit always paid to the 
patients after they had fully returned to consciousness 
in order to ascertain the final effect led regularly to the 
result that amnesia also set in as soon as the derangement 
in apperception began. 

Since that time I have guided myself as to dosing al- 
most altogether according to the variations of the care- 
fully tested capacity of apperception, and have, when these 
tests have been properly carried out, never been misled as 
to the state of matters at the moment. 

In the rare cases in which the carrying out of this pre- 
sented difficulties on account of the dementia of the pa- 
tient, or for other reasons, I observed the reaction to pain 
of the pupils, and the locomotor ataxia and utilised them 
as very welcome and valuable auxiliaries. 

The value of these auxiliaries is further increased by a 



APPENDIX II 253 

certain regularity which a systematic observation of their 
order in time would seem to show. 

The power of apperception is the most delicate indi- 
cator for the beginning of the action of the drug. Then 
come in order of sensitiveness the locomotor co-ordination 
and the pupillary reaction. The maximum action was 
consequently reached when the pupillary reaction ceased, 
whilst the Dammerschlaf condition had already begun and 
was closely related in time with the cessation of the powers 
of apperception. 

It is clear that accurate checking of the intensity of the 
action of scopolamin-morphin will not always be so very 
easy. Curiously enough, it is most difficult in the case of 
extremely demented and of highly intelligent persons. 
But an effective maintenance of artificial Dammerschlaf 
is impossible without both a continuous and skilled testing 
of the condition as to consciousness at the moment. In 
cases, therefore, where it is impracticable for the medical 
man or — as is now done in the Freiburg clinic — for a 
skilful and well-trained, experienced obstetric nurse to 
keep a close observation on the whole course of the birth, 
nothing but repeated failures are to be looked for in the 
general results. 

I myself had enough and to spare of such failures until 
I had learned carefully to eliminate every factor which 
was interfering with the action of the injections. 

The first necessity in my opinion is that the patient 
should as far as possible be shielded from all powerful 
stimulation, whether mental or physical. It is conse- 
quently best to have the patient in a room by herself, 
where nothing disturbs the quiet beyond the proceedings 



254 AUTHENTIC TWILIGHT SLEEP 

necessary for the birth. Loud conversation, penetrating 
noises, the coming and going of relatives — in short, every- 
thing that sets the patient's senses to work is carefully 
avoided. 

How greatly just these stimulations which act upon the 
sense organs can interfere is shown by the observation we 
have often made that patients have apperceived nothing of 
the birth except the crying of the newly born infant, and 
that it is from this alone that they infer that the birth 
has taken place. We have therefore made it a custom to 
convey the child as soon as possible out of hearing of the 
mother, and, if necessary, to smother its cries still sooner 
by laying a cloth over it. More recently we have reduced 
stimulation of the sense of hearing with considerable suc- 
cess by the use of antiphones, or balls of cotton wool dipped 
in oil and put into the ears. 

The sudden turning on of the electric arc lamps in our 
obstetric operating room has often just as great a dis- 
turbing effect. The sudden stimulation of the eye im- 
presses itself only too easily on a patient lying in Dam- 
merschlaf as a persistent memory, and is often the cause 
of inopportune awakening. Protection of the eyes from 
such stimulation or, if necessary, a reduction of it by dark- 
coloured cloth or coloured spectacles (snow goggles) fa- 
cilitates the maintenance of an uninterrupted artificial 
Dammerschlaf. 

The muscular sensation and the sense of balance have 
often made permanent impressions which as regards time 
lay in the sphere of the Dammerschlaf. The feeling of 
being lifted, of the transportation, has often remained as 
an isolated recollection. Several women can also remem- 



APPENDIX II 255 

ber a feeling that they had "suddenly become so empty," 
or that something had suddenly come out of them. They 
do not generally arrive at the conclusion that this sensa- 
tion was due to the birth of the child or of the placenta 
until afterwards, if at all. At the time when we made 
extensive use of the application of the hanging position, a 
series of patients could clearly remember that they had 
lain in a position in which the head had been downward 
and in which they had the feeling all the time of slipping 
down an inclined plane. 

The organs of touch and of perception of pain showed 
themselves, as indeed lay in the nature of the case, least 
sensitive to stimulus. Bodily pain was with relative diffi- 
culty apperceived by women in Dammerschlaf, it making 
no difference whether it was caused by pin pricks, pressure 
on the abdomen, birth-pangs, or other indignities. The first 
of the pains due to the birth-pangs to disappear from the 
consciousness are the feelings due to the contractions of 
the uterus, whilst those due to compression and dilatation 
of the soft parts are perceived for some time afterwards. 
We have utilised the smallness of the reaction of the con- 
sciousness to stimulation of the sensitiveness to pain of 
the skin by employing the Dammerschlaf as a preparation 
for Bier's lumbal anaesthesia which has been lately so 
much used for obstetric operations. The lumbal puncture, 
which is otherwise very painful, and on this account is 
retained in the memory, is deprived of its unpleasantness 
by the blunting of sensation and the beginnings of am- 
nesia. Penkert * has recorded the favourable experiences 
obtained on this point in gynaecological cases in the Frei- 

*Miinchen med. Wochenshrift, 1906. No. 14. 



256 AUTHENTIC TWILIGHT SLEEP 

burg clinic; those obtained in the obstetrical department 
will be published by me on another occasion. 

The torture of the sensations of suffocation when inhal- 
ing chloroform or ether vapour loses its terrors if Dam- 
merschlaf with its consequent amnesia is employed. 

The fact consequently already known to us from alien- 
ists' practice that for every species of sensation a certain 
limiting stimulus exists, is here confirmed. The sur- 
roundings must be such that this limit is not overstepped, 
and if any stimulations powerful enough to arouse sensa- 
tion (crying of the child, glaring light) cannot be avoided 
such stimulations must by suitable means be so reduced in 
strength as to remain "below the perception limit." 

In addition to the observation of these hints, a close 
and uninterrupted watching of the case is an unavoidable 
necessity for the proper production and maintenance of 
artificial Dammerschlaf. It alone, for example, renders 
possible a correct, that is to say, a sufiicient and yet unin- 
jurious dosage. If this is not done the result is either 
overdosing, in which case the unpleasant concomitant ef- 
fects mentioned above make their appearance, or the Dam- 
merschlaf is not uninterrupted, so that the patients retain 
in their memories events and observations made during 
isolated lucid intervals in the course of a more or less 
protracted period of amnesia. The existence of such 
"memory islands" — as I term them — is, however, ex- 
tremely injurious to the total effect. The patients con- 
nect them with one another by natural trains of thought, 
and so form for themselves a picture of the birth that pre- 
cisely because it is based upon isolated exact observations, 
gives them so much the more the idea of having a genuine 



APPENDIX II 257 

recollection of the course of the birth. Ziehen speaks in 
his Textbook of Psychiatry of this partial amnesia as 
"additive memory," an expression which, being very char- 
acteristic, I should like to use for an imperfectly main- 
tained Dammerschlaf. It is often very difficult to convince 
patients with such an additive memory how large a part of 
the whole course of the birth they had passed in sleep. 

If I have up to now shown that an almost ideal method 
of reducing pain is put at our disposal by an exact dosing 
of the scopolamin-morphin Dammerschlaf, that is never- 
theless far from saying that this favourable result may 
not be greatly decreased in value by unfavourable con- 
comitant effects. 

The concomitant effects affect subjectively the patient's 
feelings, and objectively the whole course of the physio- 
logical processes during and after birth in the case of both 
mother and child. 

Let us first discuss the subjective feelings of the patient 
during and after birth. 

Amongst the subjective effects one subjective unpleas- 
ant result of the injections should be mentioned : namely, 
thirst, which has already been briefly spoken of as a symp- 
tom of the initial action of scopolamin-morphin. 

It is well known that scopolamin has the property of 
considerably reducing the secretions of the mucous mem- 
branes so that it is indeed in various cases used for this 
particular purpose. The result is, of course, a feeling of 
thirst varying in strength in different persons. This is 
exhibited objectively in a dry tongue and dry lips. 

I have never hesitated to counteract a concomitant so 
unpleasant to the patient by giving as much liquid as was 



258 AUTHENTIC TWILIGHT SLEEP 

desired, and in spite of this have never seen any injurious 
results follow from the increased consumption of liquids. 

In particular, vomiting was hardly ever observed unless 
it had already appeared before the injections. This ap- 
plies both to the birth and the period of lying-in. There 
has likewise never been complaint of headache, diarrhoea 
or constipation, and rarely of giddiness. 

Derangements of the senses of sight and hearing have 
now and then been observed. The patients answer ques- 
tions which nobody has put, and sometimes carry on in this 
way whole conversations; that portion proceeding from 
the patient and audible to the observer shows that it is 
a rational reply to aural hallucinations of the patient, 
consisting of words and sentences. 

The sense of sight appears occasionally to have its share 
in these delusions of the senses, the patient stating that 
she sees persons and objects black. 

I have already mentioned above that mental hallucina- 
tions — aptly termed "delusions of the imagination" by 
Kraepelin — occasionally occur. 

As all these hallucinations occur only in stages of un- 
intentionally profound derangement of the consciousness, 
it is clear that the patient can afterwards remember none 
of them, so that they do not come into account as affecting 
the subjective comfort of the patient. 

More imporant both in general and in particular than 
any unpleasant concomitant effects on the subjective con- 
dition of the patient which might occur, were the objec- 
tive effects which influenced the physiological course of 
the birth and lying-in period. 

The points which were of importance in this respect 



APPENDIX II 259 

were taken into serious consideration and thoroughly ex- 
amined. 

The most important factor for a normal course of the 
birth itself is the satisfactory working of the ejecting 
forces — that is, of the birth-pangs and the straining action. 
How do they behave under scopolamin-morphin injection ? 

To clear up this question beyond dispute, it was neces- 
sary to undertake a detailed observation of the birth- 
pangs. 

As subjective impressions of the frequency and power of 
the pangs cannot be considered as objectively utilisable 
for purposes of proof, the more exact checking of the 
pangs was undertaken by recording and registering them 
in curves. This indeed made extraordinary demands on 
the time and energy of the observing staff. But, on the 
other hand, the curves give the clearest possible view of 
the pang action, both as regards itself and as regards its 
dependence on the action of the scopolamin-morphin. 

These pang curves were described in the following way 
as shown in the sketch (blackboard). The ordinate of 
the figure representing a pang indicates the interval of 
time between that pang and the previous one. The ab- 
scissa show how long it itself lasted. So the higher the 
"pang mountains" are the less was the frequency of the 
pangs. The broader the "mountains" are the more pow- 
erful the action of the individual pain, and conversely. 
It will be admitted that even at the first glance a very 
good general idea of the pang action and the influence on 
it of the injections can be obtained from these curves. And 
this idea has so much the greater title to be considered 
scientifically exact as each separate pang of each indi- 



260 AUTHENTIC TWILIGHT SLEEP 

vidual birth was recorded as regards time of occurrence 
and duration. The curves were subsequently made still 
more correct by the elimination of a source of error that 
at first was not detected. Since it has become known that 
as the action of the injections increases the exhibitions of 
pain on the part of the patients confine themselves also 
more and more to the climax of the pang, and even in 
given circumstances cease altogether, when the injections 
are producing their full effects, the pangs have been no 
longer recorded, from the signs of suffering given by the 
patient, but in accordance with the contractions observed 
by the hand of an obstetric nurse kept continuously on the 
uterus. 

Such curves were plotted altogether for a hundred and 
thirty-one births. If it is very possible by merely glanc- 
ing through them to gain an impression of the action of 
scopolamin-morphin on the pangs, one is much more en- 
titled to pronounce an objective judgment as to the fre- 
quency and number of the pangs and in particular as to 
their dependence if any upon the injections after care- 
fully going into the curves. I considered this point as so 
extraordinarily important in its bearing on the question 
of the use of scopolamin-morphin in obstetrics that it has 
been taken up for treatment by Schlimpert in the form 
of a dissertation. 

The statements which follow rest upon Schlimpert's 
laborious work (128 pang-curves) and the critical notes 
entered by me in the diary at the end of every birth. The 
figures derived from the results calculated from the 128 
curves will be found in Schlimpert's paper mentioned 



APPENDIX II 261 

above. I myself am in possession of notes of the pang 
action in 493 births. 

The pangs were recorded as excellent in 103 cases, as 
good in 273 cases, as bad from the very beginning in 39, 
and as varying in 36. In these 451 births no notable af- 
fection of the pang action by the injections was to be de- 
tected. 

In 42 cases, on the contrary, an alteration in the pang 
action was clearly observed. In 8 cases they were after 
the injection worse than before, and in 36 cases it was 
noted that they were decidedly better after than before the 
injection. How far the alteration of the pang action in 
these 42 cases was due to the drug, and in how far to 
chance would be very difficult to ascertain. 

But leaving this out of account, it is clear from the 
figures that there can be practically no question of an un- 
favourable action of the scopolamin-morphin injections on 
the pangs. 

The observation often made by bystanders that a dimi- 
nution in the power of the pangs is clearly to be seen after 
the injections is sufficiently explained by the diminution 
or cessation of subjective demonstrations of pain on the 
part of the patient, it being universally the custom to 
judge the extent of the pang action from them. If these 
sceptics are told to test the power of the pangs by placing 
the hand on the uterus, they see reason to change their 
opinion: it can be easily perceived that the processes of 
birth are continually unchanged although there are no 
outward signs of intense suffering. 

An increase of the intervals between the pangs which, 
according to Schlimpert's calculation, occasionally occurs, 



262 AUTHENTIC TWILIGHT SLEEP 

might be considered as an objection to the use of scopol- 
amin-morphin if lie bad not also frequently observed an 
increase in the duration of the pangs and also a clearly 
recognisable regulative effect of previously irregular pang 
action after tbe injections. According to my observa- 
tions, a temporary diminution in the frequency of the 
pangs was especially likely to occur if the initial dose had 
been too great. 

It could be proved in all the eight cases in which a de- 
terioration of the pangs took place after the injections, 
that large doses of morphin, such as in the newer system 
of dosing which has proved preferable do not occur at all, 
were to be held responsible. 

The second most important factor for the course taken 
by the birth is the straining action. It also deserves to be 
observed with a special care in following a birth. 

To meet the objection which might be made that I had 
observed the straining pangs of patients having a first 
child through the same spectacles as the pangs of the other 
patients, I have, in what follows, added in parentheses the 
number of the former cases to the figures showing the total 
number of births. 

In what follows, records of the intensity and nature of 
the straining pangs were made in 460 of my 500 births. 
The straining action started spontaneously in 444 cases, 
and could be described in 160 (68) as excellent, in 267 
(93) as good, and in 38 (31) as bad. 

In the remaining 16 births, the straining action was 
only applied on request, and was in 1 (0) case excellent, 
in 13 (3) good, and in 8 (4) bad. 

It will be seen from this resume that in 3.5 per cent, of 



APPENDIX II 263 

the cases spontaneous straining action did not occur, and 
that in 1.7 per cent, a satisfactory action was not to be 
obtained even on demand. 

It cannot be denied that this would be a disadvantage of 
the Dammerschlaf if it were a result of the injections; if 
this result appeared to be unavoidable and if a prolonga- 
tion of the birth followed from it. 

It is very rarely that in midwifery practice a birth 
treated without narcotics comes spontaneously to its con- 
clusion by the action of the uterine contractions alone, 
without any appreciable assistance from the straining ac- 
tion ; from this it may be concluded that the deterioration 
or absence of reflex straining action in my cases is a 
result of the scopolamin-morphin injection. 

On the strength of the experience gathered on the sub- 
ject of artificial Dammerschlaf, I have indeed come to 
the conclusion that the above-mentioned unfavourable ef- 
fects upon the straining action are in so far results of 
the Dammerschlaf that they occur when, by an erroneous 
system of dosage, large quantities of narcotic are adminis- 
tered to the organism in a single dose. Morphin has 
proved to be in this respect particularly dangerous; its 
property of suppressing the pangs and straining pangs 
even when administered in relatively small quantities, has 
been indeed for long well known enough. This is far less 
true of scopolamin ; which, as a matter of fact, only exerts 
an unfavourable influence upon pangs and straining action 
if administered in very large quantities at a time. 

Schlimpert has also observed the same relation between 
the extent of the clouding of the consciousness on the one 
hand and the straining action on the other. 



264 AUTHENTIC TWILIGHT SLEEP 

He found that in 20 cases of ordinary Dammerschlaf 
the reflex straining not only was not abolished, but in most 
cases was even good or excellent. In 131 cases, in which 
there was an advanced degree of stupor, 22 cases were 
noted in which the straining pangs were more or less bad, 
and in part only occurred on demand. Apart from the 
fact that of 131 births a certain number even without 
scopolamin would exhibit a defective straining action, ten 
of these cases were either simply complicated or part 
doubly complicated by narrow pelvis, premature or early 
bursting of the membrane, deep transverse position of the 
child, or large child, so that other explanations could be 
offered besides that of the effect* of scopolamin-morphin. 

I have drawn two lessons from the observations of the 
relations existing between pangs, straining action, and 
Dammerschlaf. 

In the first place, too large quantities of scopolamin- 
morphin must not be given at one time. One begins, con- 
sequently with the relatively small doses mentioned above, 
and gradually adding to them induces the action, so to 
speak, surreptitiously. Larger quantities administered in 
a limited time bring about indeed a more rapid effect, but 
also often — not always — involve a danger of undesirable 
concomitant effects upon the pang action. 

Second, the quantity of morphin introduced into the 
body must be kept as small as the desired narcotic effect 
permits. The higher doses of morphin which I at first 
used to give have, in addition to the comatose condition 
of the patients described above, also on their consciences 
the drawbacks noted during the observation of the pang 
action. As it is possible without injuring the Dammer- 



I 



APPENDIX II 265 

schlaf to keep as low as .1-.15 morphin for the whole 
course of the birth, it lies entirely in one's own power by 
following the directions for dosing which have been found 
most suitable to avoid any unfavourable influencing of 
the forces performing the task of birth. 

A consideration of the frequency of operations shows 
how little the penalty paid for this knowledge influenced 
my statistical result. Of 506 children, 49 were delivered 
with the forceps, 9 by rotation and extraction (2 of them 
after vaginal csesarean section), 1 by classical csesarean 
section, and 4 by subcutaneous hebotomy. (The forceps 
being also used in 1 case.) 

This amounts to an operational frequency of 12.60 per 
cent, which is about the same as the operational frequency 
calculated by Ploeger as being 12.78 per cent, of the gynae- 
cological wards of the University of Berlin, which I quote 
here for purposes of comparison. 

Of the 63 women delivered operatively, 37 were having 
their first child, and 26 a second or subsequent one, so 
that of the former 16.2 per cent. (Ploeger, 11.19 per 
cent.) of the births were ended operatively and of the 
latter, 9.7 per cent. (Ploeger, 13.07 per cent.) 

These are figures from which no protraction of the 
duration of birth due to the use of artificial Dammerschlaf 
can be deduced which can in any way influence the ques- 
tion of its applicability. 

Comparative statistics of the duration of birth must 
also give important information as to the effect of the in- 
jections on the forces of ejection. I am indebted for the 
following figures also to Schlimpert's paper, mentioned 
above. 



266 AUTHENTIC TWILIGHT SLEEP 

The duration of birth was recorded in 128 cases. The 
average for 

First Births 18 hrs. 23 min. 

Subsequent Births 13 " 58 

Both Classes 16 " 11 " 

It should be remarked that only two-thirds of the cases 
were uncomplicated head presentations. 

The following figures have been given for the average 
duration of first and other births taken together : 

Spiegelberg 17 hrs. . . m 

Lumpe, (1,045 births) 16 " 30 

Veit, 9,731 head presentations, in and out 

patients 14 " 36 

Bumm, uncomplicated head pres 12 " 30 

Simpson 10 " 38 

for Boys 9 " 34 



Berlinsky 19 



Lachapelle^ forGirlg Q u dQ 



The following averages have been given for the duration 
of birth for first births alone : 

Spiegelberg 20 hrs. . . min. 

In and Out Patients.... 19 " 30 " 

Veit— 

In Patients alone 20 " 

Massen 16 18 

Wolf 18 " 27 

Bumm 15 

Suamensky 17 " 54 

Parischen 17 " 39 

For subsequent births alone: 

In and Out Patients 11 " 50 



APPENDIX II 267 

Veit— 

In Patients only 15 hrs. 8 min. 

For Second Births 8 " 35 " 



For Subsequent Births 8 " 6 " 

For Second Births 11 " 10 " 

Wolf— 

For Subsequent Births 10 " 42 " 

Suamensky 12 " 1 " 

Parischen 11 " 25 " 

Bumm 10 " .. " 



Taking into account that Veit's and Bumm's figures 
refer only to uncomplicated head presentations, and if we 
leave out of account the extreme values given by Lacha- 
pelle and Berlinsky, it may be said that the duration of 
the Dammerschlaf births does not vary from that of the 
others. 

Schlimpert has also collected figures regarding the 
duration of the ejection period alone. He chose 93 cases 
in which the records of the birth, in addition to exact 
statements of the times, also contained the note, "Patient 
in deep stupor." He selected these, in order, by using 
precisely such births occurring under an extremely deep 
action of scopolamin-morphin, to avoid the objection that 
the results might have turned out so favourable by chance 
or by defective analysis of the cases. He ascertained that 
the average duration (for all births) was : 

For First Births 3 hrs. 27 min. 

For Others 1 hr. 47 " 

Against these may be set the following figures given 
for ejection (for uncomplicated head presentation only) : 



268 AUTHENTIC TWILIGHT SLEEP 

For First Births, by Veit, 1 hr. 45 min; by Bumm, 1 hr. 30 min. 
For Other Births, by Veit, 1 hr. min; by Bumm, hr. 45 min. 



Von Winckel opposes some higher figures to these most 
strikingly low ones. He found for first births, 1% to 7% 
hours. For other births, % to 1% hours. 

A comparison with the figures given by Veit and Bumm 
shows a difference in the ejection period to the disadvan- 
tage of the scopolamin-morphin births. As, however, the 
average for the duration of the whole birth nearly agrees 
for all three, we are almost driven to the supposition as 
an explanation for the differences existing in the ejection 
period that a different stage was regarded as the begin- 
ning of the ejection period. The indications regarded by 
many authorities as marking this beginning — complete 
distention of the muttermund, the first presswehe, or the 
bursting of the membrane— occur at times that may differ 
fairly widely. 

To objections which may possibly not be laid by this 
attempted explanation of the difference in the duration of 
the ejection period, I would reply with the following 
considerations : 

First, the difference in time is so small as to be practi- 
cally of no account. 

Second, I consider the general advantages of artificial 
Dammerschlaf to be far too great to be in any way out- 
weighed by the disadvantage, if it is in fact present at all, 
of such a minute retardation of the birth. 

Third, the figures were intentionally derived from cases 
in which the consciousness was especially profoundly af- 
fected. 



APPENDIX n 269 

As, however, the artificial Dammerschlaf ought to keep, 
if carried out properly, as nearly as possible to the lower 
limit of the region of Dammerschlaf, the figures given 
above would be too unfavourable for births with the less 
profound action on the consciousness which we aim at. 
In addition, we must remember that large doses of mor- 
phin must be held responsible for any deterioration in the 
muscular action of the birth that may occur. As I, how- 
ever — also for the sake of the child — have long been using 
doses with a much reduced quantity of morphin, the data 
calculated by Schlimpert would be much improved upon 
by figures based upon the present and different dosing. 

In addition to this extremely deep affection of the 
consciousness, there is also a second factor which pre- 
vents us from placing Yeit, Bumm, and Schlimpert's fig- 
ures on absolutely the same footing — the circumstance, 
namely, that Veit and Bumm included only uncomplicated 
head presentations in their statistics, while Schlimpert's 
figures included all the complications that occurred — and 
they did so in a third of the total number of cases. 

And, finally, even if a prolonged action on the birth 
appeared in more cases than it has yet been observed to, 
that would still be no reason for casting discredit on the 
use of artificial Dammerschlaf. For since we require a 
new injection every two to four hours, about, to preserve 
an uninterrupted effect, we have it entirely in our power 
to avoid any retarding action of scopolamin-morphin 
which may really exist. 

If we see that a patient responds to scopolamin-morphin 
by a weakening or cessation of the straining action, we let 



270 AUTHENTIC TWILIGHT SLEEP 

her wake up and without the scopolamin-morphin add her 
voluntary lahour to the involuntary contraction. 

In such a case, nothing is lost and much is won, inas- 
much as we have spared the patient completely the suffer- 
ings of the initial period. 

The intensity of the pangs in the placenta period gen- 
erally runs parallel to that in the initial and ejection 
periods. 

We are consequently entitled to assume that if no appre- 
ciable diminution of the pang action in consequence of 
artificial Dammerschlaf has occurred during the birth, 
effects of this kind will not make themselves apparent 
in the after-birth period either. 

The resume compiled as to the course of the placenta 
period in my Hve hundred births confirms this conclusion : 

The placenta was ejected spontaneously (with or with- 
out the voluntary straining action) 280 times (56 per 
cent.) ; in 251 of these cases without haemorrhage, and in 
29 cases with slight haemorrhage which ceased on employ- 
ment of massage of the uterus and did not amount to over 
500 grms. 

In 215 cases (43 per cent.) it was ejected on pressure 
or Crede; in 145 cases without haemorrhage; in 50 cases 
with slight and in 20 with severe haemorrhage. 

In 3 cases (6 per cent.) finally manual detachment of 
the placenta was necessary. There were two additional 
cases which I have not included in calculating the percent- 
ages under this heading. The operation in them — one a 
classical and the other a vaginal caesarean — was simply an 
invariable portion of the course of these operations. On 
account of what has been said as to the unfavourable influ- 



APPENDIX II 271 

ence exerted by scopolamin-morphin on the placenta pe- 
riod, I will shortly describe in more detail the circum- 
stances in which a manual detachment had to be carried 
out in the three cases mentioned above. 

One was a woman who had already undergone eight 
manual detachments : that is, in every one of her previous 
accouchements. Detachment was indicated by the appear- 
ance of fever six hours after the birth of twins. In the 
second case, operation was resorted to nine hours after 
birth because in spite of all efforts the placenta was re- 
tained in the uterus. In the third case it was necessary on 
account of haemorrhage after a premature birth. 

In the 495 cases of a non-operative birth of the placenta 
(99 per cent.) there were consequently 20 cases (4 per 
cent.) of somewhat severe haemorrhage: i.e., with a loss 
of over 500 grms. of blood. Haemorrhage was once the 
indication for manual detachment. Digital examination 
of the uterus after the ejection of the placenta was in 
addition carried out in four cases, since it was impossible 
to be absolutely certain that the greatly disintegrated 
placenta was complete. In no case was a torn-off cotyledon 
found. 

That digital examination was resorted to in the absence 
of haemorrhage simply on account of difficulty in judging 
of the completeness of the placenta was due to considera- 
tion of the fact that the danger of intra-uterine manipula- 
tion with a negative result immediately after the birth is 
to be considered as immeasurably less than that of one 
during the lying-in in cases in which a retention of the 
cotyledon which had up to then given rise to no symptoms 



272 AUTHENTIC TWILIGHT SLEEP 

suddenly occasions the much more serious complications 
of severe anaemia or puerperal infection. 

Comparative statistics of manual detachment of the 
placenta give results very favourable for my five hundred 
births. 

The following table, in which the frequency per cent, 
of manual detachment is given by the most various au- 
thorities, shows this clearly * : 

Clarke 0.3% M'Clintock u. Hardy 0.9% 

Ahlfeld 0.3% Stadfeld (by Ahlf. Meth.) 1.0% 

Felsenreich 0.4% Dammann (by Crede) 1.2% 

von Both-Ahlfeld 0.6% Lindfors 1.4% 

Stadfeld (by Crede's Eras 1.6% 

method) 0.6% Fischer (by Credos meth. ) . 1.6% 

Gauss (this paper) 0.6% Zeuschner 1.7% 

Leopold 0.8% Galea 2.0% 

Stadfeld (by Dubl. meth.) .0.8% Fischer (by Ahlf eld's meth.) 3.2% 

Dammann (by Ahlfeld Baumgartner 3.4% 

method) 0.8% Maygrier 7.3% 

The non-operative ejection of the placenta took place as 
to time 

In under y 2 hour.... 205 cases Under 2 hrs 52 cases 

« " 1 " 132 " " 3 " 31 " 

" iy 2 hrs 58 " " 6 " 16 " 

That is to say, in 447 cases under 2 hours, and 63 cases 
from 2 to 6 hours. 

The comparison of figures as to the method of ejection 
gives also results very favourable to my 500 births. 

The placenta was born spontaneously or by conscious 

* Winckel's Handbuch, 1. Band, 2. Halfte — Ahlfeld, Zeitschrift fur 
Ged. u. Gym, Bd. 57, Heft. 1, 



APPENDIX II 273 

effort, in Ahlf eld's 406 births, in 23 per cent. ; in my 500 
births, in 56 per cent. By pressure or Crede in Ahlf eld's 
births, in 77 per cent. ; in my births, in 43 per cent. 

Derangements of the placenta period, being one of the 
fears most often expressed with regard to the nse of sco- 
polamin-morphin Dammerschlaf, this comparison was of 
especial interest and value to me. 

In general, my figures are completely normal, espe- 
cially when it is remembered that the custom of expelling 
the placenta by pressure after half an hour or more on 
principle, does not exist in the Freiburg clinic. Under all 
circumstances — haemorrhage of course excepted — the spon- 
taneous detachment of the placenta is awaited, and the 
expulsion, if up to that time it has not already taken place 
spontaneously, is left to the straining action of the patient 
or facilitated by gentle pressure on the abdomen, not on 
the uterus. Use is not made of more violent methods, such 
as vigorous Crede or manual detachment, until the pla- 
centa has delayed its appearance for more than 4 to 8 
hours. 

And, finally, an effect of the scopolamin-morphin injec- 
tion also on the puerperal functions of the body is not 
inconceivable. It has already been mentioned that sco- 
polamin-morphin affects the glands and mucous mem- 
branes, drying them and diminishing the secretions. In 
consequence, it is hardly superfluous to discuss the ques- 
tion how women delivered in scopolamin-morphin semi- 
narcosis behave with regard to milk secretion during the 
puerperal period. 

With this object I have taken the trouble to place 
beside 200 scopolamin-morphin births another 200 with- 



274 AUTHENTIC TWILIGHT SLEEP 

out scopolamin-morphin which took place during the same 
period for comparison. 

It turns out that the following percentages were able to 
suckle their children: 

Without scopolamin-morphin With scopolamin-morphin 

137 68.5% 134 67% completely 

8 4% 15 7.5% partially 

55 27.5% 51 . . . . 25.5% not at all 

It can be seen from this that the scopolamin-morphin 
injections exert no injurious influence on the milk secre- 
tion. 

I was not able to study the process of involution of the 
genital organs and ascertain whether this was in any way 
affected by the use of scopolamin-morphin; the patients 
being for lack of space generally, if circumstances permit, 
discharged on the seventh day; but no noticeable evil ef- 
fects on the involution and in particular no haemorrhage 
during the lying-in attracted my attention. 

To avoid detrimental effects on the organism of a more 
general nature which might be attributed to the use of 
scopolamin-morphin, I have made further investigations 
of another kind. 

The accurate investigations of Benno Miiller of Ham- 
burg have attracted more general attention to the effects 
of various types of narcosis on the parenchymatous or- 
gans, especially the kidneys. This suggested the carrying 
out of similar investigations for scopolamin-morphin Dam- 
merschlaf. 

I have tried to do this both clinically and by experi- 
ments on animals. 



APPENDIX II 275 

Keeping in mind the fact that injuries to the paren- 
chyma of the organs, if present, could best be detected in 
the urinary secretions, I examined the catheterised urine 
of 50 patients, 44 of whom were confined in scopolamin- 
morphin Dammerschlaf and 6 in scopolamin Dammer- 
schlaf. Specimens were taken before the injections began 
to take effect and 24 hours after the birth had taken place. 

Three of the scopolamin-morphin patients showed albu- 
men at the first examination; at the second it was no 
longer present. In two cases urine which had been free 
from albumen at the first investigation was found to con- 
tain it at the second. The remaining 45 patients had no 
albumen either during the birth or whilst lying-in. 

ISTow it is well known that the mean frequency of al- 
buminuria during parturition is, according to Plaischlen, 
16.9 per cent., and according to von Winckel, 19.4 per 
cent. ; the latter author stating that in from one-fourth to 
one-third of the cases in question it could be shown that the 
albuminuria was purely a continuation of that existing 
during pregnancy. 

There is consequently so much the less reason to as- 
sume that the two cases of albuminuria during lying-in 
observed by me were anything but transitory occurrences. 

I have in addition made experiments on rats, guinea 
pigs, and rabbits, thus pursuing the same object by patho- 
logical anatomic methods. By means of injections I 
brought the animals into a state of intoxication and then 
killed some of them in this condition and others after it 
had passed off, examining the freshly extracted organs by 
the methods used by Benno Miiller. 

I was also anxious to ascertain at the same time whether 



276 AUTHENTIC TWILIGHT SLEEP 

possibly a difference between the effects of scopolamin- 
morphin, scopolamin alone, and morphin alone on the 
parenchymatous organs of the kidneys could be detected 
by pathologico-anatomical means. 

As these investigations became very extensive and as 
the parallel between Dammerschlaf in human beings and 
the narcotic action in animals can only be used within 
limits as a proof of the innocuousness of the scopolamin- 
morphin Dammerschlaf, I have relinquished the idea of 
discussing the question in this paper. For the results of 
these experiments on animals I refer to a paper to be pub- 
lished elsewhere. 

There is still another objection which I think I ought 
to refute in advance. It is well known that surgeons ac- 
cuse ether narcoses of predisposing to thrombosis of the 
crural veins; although up to the present no sufficient ex- 
planation of this allegation has been given, yet the possi- 
bility of such a connection between a narcotic and the 
blood vessels cannot be denied offhand. 

Thrombosis of the veins of the thigh being of special 
importance for the period of lying-in, it must be of equal 
interest to ascertain whether scopolamin-morphin also has 
any connection with thrombosis. 

Of the cases of this kind observed during three years in 
the Freiburg clinic, seven were of crural thrombosis and 
two of embolism. Four of the patients were confined with- 
out scopolamin-morphin, the remaining five were delivered 
in Dammerschlaf. 

What at first sight appears to be a strikingly higher 
percentage of scopolamin-morphin Dammerschlaf cases 
takes a different aspect when one adds that one of the 



APPENDIX II 277 

women had already had a thrombo-phlebitis during preg- 
nancy, and that three of the others developed it after 
undergoing hebotomy, of which thrombosis unfortunately 
still forms one of the most undesirable complications. 

~No other complications during lying-in were observed, 
which could be attributed to the action of the narcotic; 
and no exitus lethalus can be laid at its door either. 

On the other hand, a special point is deserving of more 
attention. Of the three cases of convulsions which oc- 
curred among the women confined in Dammerschlaf, two 
were cases of puerperal convulsion ; the third patient, after 
having had two attacks before the Dammerschlaf, had 
only one more, which was followed by no others. 

The treatment of convulsions by means of narcosis has 
fallen indeed more and more into disuse ; but nevertheless 
it is impossible to deny that the narcotic reduces the sensi- 
tiveness of an eclamptic patient towards stimuli. Al- 
though I by no means wish to contend that the late ap- 
pearance of the attacks and final recovery in the case of 
our patients was due to the effect of the scopolamin-mor- 
phin, the cases are yet so much the more noteworthy in 
that these three cases with the exception of one other (no 
scopolamin-morphin) are the only ones which, in spite of 
otherwise absolutely identical treatment, did not terminate 
fatally of the seven cases of eclampsia observed in the 
course of one and a half years. This feature is indeed 
very rare in Baden, but when it does occur appears to be 
all the more severe. It would no doubt be well worth while 
to test by the investigation of a larger number of cases 
whether scopolamin-morphin Dammerschlaf in addition to 



278 AUTHENTIC TWILIGHT SLEEP 

causing earlier delivery is capable of playing a material 
part in the cure of eclampsia. 

It will be clearly seen from the foregoing that as far as 
the mother is concerned there can be no question of in- 
jurious incidental effects of the Dammerschlaf. It re- 
mains to be seen whether the child is equally fortunate. 

As the possibility of the vital functions of the newborn 
child being influenced by the narcotic cannot be dismissed 
a priori, I did not in my first cases make use of the injec- 
tions unless I were already in a position to end the birth 
at once at any moment; that is, in general, never till to- 
wards the end of the initial stage. As no injurious ef- 
fects of the injections on the child before delivery could 
be detected by the most careful observation, I soon con- 
siderably increased the duration of the Dammerschlaf. 

The experience obtained from the births hitherto ob- 
served has absolutely convinced me of the innocuousness 
of Dammerschlaf in regard to the children. This confi- 
dence is best shown by the rule now invariably followed of 
beginning the injections as soon as the pangs occur at 
regular intervals and are found unpleasantly painful by 
the patient, without any regard for the stage which the 
birth may have reached or the complications that may be 
present. 

And now as to the child itself : 

Of the 506 children, including six cases of twins, 500 
(98.8 per cent.) were born alive, and 6 (1.2 per cent.) 
were still-born. 

Of the 500 children born alive, 316 (63.2 per cent.) of 
all born alive were born vigorous and lusty ; that is to say, 
did not vary in their behaviour from the normal. Eour of 



APPENDIX II 279 

them were born prematurely, and died after a short time. 

One hundred and nineteen (23.8 per cent.) of those 
born alive showed, on the other hand, a condition that led 
us to conclude that the injections had affected the child's 
organism. This condition of intoxication presents some- 
what of the following appearance : 

The newly born infant takes one deep breath at the mo- 
ment of birth with a more or less loud cry, and then lies 
sometimes motionless and sometimes moving its limbs, the 
heart's action continuing. 

It is only now and then that a short breath is taken, so 
that between them the appearance of recurring cyanosis is 
presented in consequence of the accumulation of carbonic 
acid gas and the lack of oxygen in the body. At the same 
time it opens its eyelids but then immediately allows them 
to close again slowly, as if tired. The diameter of the 
pupil is meanwhile so extremely various that no inference 
can be drawn as to the intensity of the narcotic action. 
In the majority of cases the diameter was equal to or 
greater than the average. 

The following symptoms are also especially character- 
istic of this intoxication-like condition. The children re- 
spond vigorously to stimuli, but the reflex muscular action 
so occasioned is often quite suddenly interrupted before 
it is complete, as if the carrying out of the intended 
movement had been all at once forgotten. The action of 
the heart meanwhile is clearly dependent on the nature of 
the breathing. As the interval from the last breath in- 
creases, the foetal pulse slows down gradually to about 60 
beats, rising immediately again to the normal frequency as 
soon as the next breath is taken. This process is continu- 



280 AUTHENTIC TWILIGHT SLEEP 

ally repeated at continually diminishing intervals until the 
breathing either spontaneously or in consequence of ex- 
ternal causes becomes regular. Erom the moment at which 
regular breathing begins, the children no longer show any 
deviation from the normal. 

In my earlier cases this condition inspired me with 
great uneasiness, and I consequently considered myself 
bound to immediately commence measures for resuscita- 
tion. 

Gradually, however, by cautiously delaying my inter- 
vention, in suitable cases, I found that this anxiety was 
exaggerated, so that at various times for the sake of ex- 
periment I calmly waited to see whether the child would 
begin to breathe properly without any outside interven- 
tion. Various infants treated in this way for over fifteen 
to twenty minutes established regular breathing without 
assistance, the breathing action becoming more and more 
frequent, and finally absolutely regular. If the question 
is asked whether children born in this condition of intoxi- 
cation would get over their apnoea or oligopnoea even with- 
out medical assistance, we can answer yes with that degree 
of probability which we in medicine have a right to expect. 

In spite of this, I have hitherto considered it my duty 
not to leave the house so long as a patient was still under 
the influence of scopolamin-morphin, and until we have 
the experience of a considerably larger number of cases 
than I yet have at my disposal I shall also consider it my 
duty in future to always be in attendance, ready to render 
assistance if necessary. If, in the case of one section of 
children born oligopnoeic, I delayed taking action, at all 



APPENDIX II 281 

events for a time, yet in the case of the others I began im- 
mediately with efforts for resuscitation. 

It was found that slight tickling of the skin was, as a 
rule, sufficient to produce regular deep breathing and loud 
crying. 

The quickest and surest method was always a rhythmic 
massage of the heart, probably principally because this 
method combines tickling with a direct influence on the 
heart and respiration. 

Asphyxia, which is the most serious breathing difficulty 
at birth, does not occur as a result of scopolamin-morphin, 
and the percentage of these rare cases, due to various 
causes, is the same as it was before the introduction of 
Dammerschlaf. 

I have arrived at the following explanation of this very 
peculiar condition : 

The child is born with a quantity of the narcotic re- 
ceived through the placentary respiration. 

The first gasp takes place at the moment of birth, prob- 
ably on account of the joint action of various factors, such 
as sudden variation of pressure, cooling of the skin, me- 
chanical irritation of the skin, in conjunction with the 
stimulation of the centre of respiration through lack of 
oxygen and accumulation of carbonic acid. 

If the child remains now tranquil the chemical irrita- 
tion of the centre of respiration only produces in the fu- 
ture continuous breathing. 

In the case of babies born during the mother's Dam- 
merschlaf, however, the stimulation of the centre of res- 
piration is not physiologically strong enough; it is per- 
haps weakened by the effect of the narcotic and requires 



282 AUTHENTIC TWILIGHT SLEEP 

first a greater overcharge of the blood with carbonic acid, 
and a more pronounced lack of oxygen, eventually even 
renewed tickling to start and maintain regular breathing. 

The favourable and prompt effect of resuscitation I may 
compare to the similar effect of a flywheel: once set in 
motion, it is kept in motion permanently by small, regu- 
larly active forces which would not have been sufficient to 
start it. 

The main point is, therefore, to get the oligopnoeic 
children through the difficulty of the sluggish reaction of 
the centre of respiration by means of external stimulation 
in order to attain a prompt regulation of the life func- 
tions. Although I do not believe that this intoxicated con- 
dition harbours any serious dangers to the organism, I 
have, nevertheless, taken occasion to avoid it experimen- 
tally by modifying the dosage. 

On the strength of my observations, I thought that the 
intoxicating effect was caused in the first line by the dose 
of morphin, and I tried, therefore, to lessen same or even 
avoid it altogether whilst maintaining or eventually in- 
creasing the dose of scopolamin. 

These experiments of dosage, their influence upon the 
muscular action in labour, as well as upon the conscious- 
ness, having already been commented upon, had the inter- 
esting result, with regard to the child, that a curtailment of 
the dose of morphin permitted me to avoid the unwillingly 
taken risk of causing oligopnoea or apnoea respectively 
without rendering uncertain the establishing of the Dam- 
merschlaf. If the quantity of scopolamin was increased 
beyond a certain limit, eventually even omitting morphin 
entirely, slight intoxicating effects were observed in the 



APPENDIX II 283 

child which were the more pronounced the dimmer the 
state of consciousness of the mother. If the first injec- 
tions were heavily overdosed, the intoxicating effect upon 
the child took place sooner than in its mother; whilst the 
latter still retained unclouded consciousness, the former 
was eventually horn in a state of apnoea. Morphin by 
itself causes deep apnoea in the child at birth if any 
progress of the delivery took place at all. 

In the same manner as the condition of the newborn 
child may be taken as the best indication as to the correct- 
ness of the dosage applied, it is possible, according to my 
experience, to inversely infer the condition of the child to 
be expected at birth from the degree of dimness of the 
consciousness. 

If by careful observation of the distinctive signs an 
overdosing of the mother and an overloading with morphin 
unnecessary for the production of Dammerschlaf is 
avoided, incidental effects in the newborn child can always 
be avoided. 

The first impression of my results seems to contradict 
this statement; the consideration of several facts, how- 
ever, easily explains this apparent contradiction, 

As I applied the first dosages without knowledge of the 
effect to be expected of the scopolamin-morphin in general, 
overdosage was unavoidable. 

Only gradually I then learned the objectionable effect 
of the quantities of morphin that are superfluous in pro- 
ducing Dammerschlaf, which effect increased the statistics 
by a number of oligopnoeic children. 

Finally, after realising the relative harmlessness of 
overdosing, I aimed directly at ascertaining experimen- 



284 AUTHENTIC TWILIGHT SLEEP 

tally which doses of scopolamin and morphin were suffi- 
cient to induce artificial Dammerschlaf in the mother and 
child within a short time and without secondary effects. 

If we divest the statistics about the primary condition 
of the child of these failures resulting from intentional 
and unintentional experiments, and base them on the dos- 
age found by me to be suitable, then the results for the 
children are as favourable as I have already pointed out. 

Of 50 children, the mothers of whom had received as a 
first dose .0006 scopolamin and .01 morphin, and after 
that only repeated injections of .00015-.0003 scopolamin 
without morphin, only 5 (10 per cent.) showed oligopnoea. 
In these five instances I had to achieve the desired effect 
within from 2 to 6 hours, for which purpose four times 
.0012, once even .0015, scopolamin was necessary; the 
consequence of these high dosages of scopolamin, that were 
too strong for the space of time under consideration, was 
oligopnoea of the child. In the remaining 45 cases in 
which there was sufficient time to produce the Dammer- 
schlaf more slowly, the secondary effects on the child did 
not appear in consequence of the dosage being calculated 
correctly. 

The advisability of the slowly acting dosage containing 
little morphin holds therefore good also with regard to 
the initial state of the newborn child. 

Sixty-five of the children born alive (13 per cent.) were 
asphyctical. Forty-seven times the asphyxia could easily 
be explained without having to assume an effect of sco- 
polamin-morphin. Twenty-two times a long duration of 
the process of the birth with normal, 11 times with narrow 
pelvis, 7 times fever of the mother, and 6 times tight 



APPENDIX II 285 

twining round of the umbilical cord were noted; twice 
prolapsus of the umbilical cord, 4 times a difficult oper- 
ative extraction of the child, once eclampsia of the mother, 
were observed ; 3 times a fluctuation of the child's cardiac 
sounds were ascertained even before the first injection. 

Eighteen times, finally, no sufficient explanation of the 
asphyxia could be found. Nevertheless, it would not do to 
connect the asphyxia in these instances with the effect of 
scopolamin-morphin. In part of the cases the mother was 
not yet in the Dammerschlaf at the time the child was 
born ; moreover, in all the children born asphyctically the 
symptoms of intoxication, which are characteristic of oli- 
gopnea, were lacking; and finally it is not absolutely al- 
ways possible to explain every asphyxia of the child. 

Five of the children born asphyctically could not be per- 
manently restored to life, in spite of intensive and ex- 
tensive efforts to that end. These cases require a more 
detailed explanation. 

One child was so seriously asphyctical that it did not 
recover any regular respiratory and cardiac function at 
all. I entered the room in this case after the midwife had 
kept back the big head of the child nearly one hour in 
order to prevent the tearing of the vagina ; as I observed 
meconium, I became suspicious. I found a quite irregu- 
lar, much slackened heart beat, and allowed, therefore, 
the head to come out, after which I found the child to be 
in the above-mentioned condition, from which it did not 
recover. 

In two instances the child had aspired quantities of 
mucus when it was born spontaneously — before the for- 
ceps could be used on account of fluctuating cardiac 



286 AUTHENTIC TWILIGHT SLEEP 

sounds ; although it was possible to save them with strenu- 
ous efforts to restore life, especially in one case by an in- 
fusion of the vein of the umbilical cord with sodium 
chloride according to Schiicking, both succumbed later on 
to pneumonia. 

The fourth child was born with the aid of forceps on 
account of the long duration of the birth caused by nar- 
rowness of the pelvis after the head had entered the pelvis. 
It was deeply asphyctical, but, though recovering after a 
subcutaneous infusion of fructosat of natrium, it died the 
following day with the symptoms of cerebral injury. The 
postmortem examination showed a large hsematoma cover- 
ing the entire top of the skull. 

A fifth child showed slight cerebral symptoms in conse- 
quence of the use of forceps necessitated by slow expul- 
sion, which symptoms seemed to be disappearing ; about 5 
hours later the re-appearing symptoms led to the death of 
the child, the postmortem examination showing merely an 
abnormal thinness of the skull. The question of the pos- 
sibility of intoxication was answered in the negative by 
the examinator. 

Besides the above three children that died as a result 
of an injury received at birth, &ve children died off during 
birth. 

One was already dead when the mother was received. 

One died in utero, because an enforced birth was de- 
sisted from on account of placenta prsevia, shortly after 
the indirect turn on the foot had been accomplished. 

One died — after a very long duration of the birth with 
narrow pelvis — in consequence of the infant's cardiac 



APPENDIX II 287 

sound being badly controlled when its bead bad already 
deeply entered tbe pelvis. 

One was brougbt dead into tbe world in consequence of 
technical difficulties in a turning and extraction rendered 
necessary by a prolapsus of tbe umbilical cord. 

One, finally, was lost as it was born unobservedly in a 
transverse position and tben remained with tbe bead in tbe 
vagina, manifoldly wound witb tbe cord. 

Tbis last case needs a tborougb explanation. 

I was busy witb tbe preparation and completion of a 
manual placentary solution wbile tbis transverse position 
took place in a bed close by, watcbed, tbougb badly, by a 
midwife student. 

As tbe motber was in tbe scopolamin-morpbin Dammer- 
scblaf, sbe did not notice tbe unexpectedly rapid birtb; I 
personally made tbis very disagreeable discovery wben 
lifting tbe blanket, tbat tbe cbild tbat bad certainly still 
lived before tbe beginning of tbe disinfection of my bands, 
lay dead and balf born between tbe tbigbs of tbe motber. 

Tbis accident can be ascribed to tbe scopolamin-mor- 
pbin Dammerschlaf in so far only as tbe motber in labour 
could not notice tbe birtb herself. 

Tbis very circumstance illustrates drastically tbat wben 
using tbe Dammerscblaf a permanent supervision and con- 
stant readiness to give assistance is an essential condition ; 
if tbis condition is complied witb, no sucb accidents can 
happen. 

Now, somebody might object that the effect of scopola- 
min-morpbin in tbe child might only assert itself in child- 
bed or at a later time. 

Against tbis objection the following may be said: 



288 AUTHENTIC TWILIGHT SLEEP 

In the course of the first two weeks postpartum, 18 chil- 
dren (5.94 per cent.) that had survived the first three 
days postpartum, died : 5 from infection of the navel and 
intestines, 10 from debility through premature birth, and 
3 in consequence of malformation. 

It cannot very well be asserted that these statistics dem- 
onstrate a prejudicial effect upon the child by scopolamin- 
morphin within the first weeks of its life. 

But in order to be able to still more thoroughly remove 
eventual doubts, I have tabulated my results in comparison 
with results obtained with children born here from 1895 
till 1904, as far as their weight exceeded 2,500 grms. at 
birth. 

It will be seen that 

Among the latter Among mine 

5.8 per cent. 1.0 per cent. were still-born, of which 

1.5 per cent. 0.2 per cent. were dead previously, and 

4.3 per cent. 0.8 per cent. died under observation. 

4.0 per cent. 2.6 per cent. in the first 9 days postpartum. 

0.3 per cent. 1.0 per cent. died from injuries received at 

birth. 

3.5 per cent. 1.6 per cent. from other causes. 

About the objection that unfavourable consequences of 
the Dammerschlaf may occur later on, there remains to be 
said a few words. 

Vague suppositions are of no weight ; in order to make 
possible a conclusive, scientific criticism, a large number 
of investigations is necessary with regard to the later fate 
of the children, which would only be possible many years 
afterwards. 

If we may form a general opinion from the later con- 



APPENDIX II 289 

dition of health of the children of private patients which 
can easily be kept track of, we may say from the observa- 
tions made till now that within the first year there can 
be no talk about an injury to the children in their general 
and especial development on account of the employment of 
the artificial Dammerschlaf. 

In order to carry out a large series of investigations, a 
sufficiently large number of births in the Dammerschlaf is 
necessary; to which investigations our klinik has taken 
pains to contribute. 

Scientific experiments on such a basis and with such 
results are justified ; seeing that the question is still open, 
everybody may have his own opinion about it ; but he will 
not, at length, be able to resist the demonstrative force of 
exact investigations. 

A few words remain to be said about counter-indications 
of the scopolamin-morphin Dammerschlaf. 

First of all, I regard primary pains as a counter-indica- 
tion. On the one hand, these feeble first pains are not 
worth the trouble of making an injection; and, on the 
other, relatively large doses of scopolamin-morphin would 
be necessary to maintain the Dammerschlaf over a long 
time and the quantity would be out of proportion to the 
object aimed at. 

Furthermore, I avoid the Dammerschlaf in cases where 
the observation of the consciousness enables me to make 
important conclusions a posteriori as to the general state 
of health, such as debility, fever, anaemia, in which in- 
stances the action of the scopolamin-morphin would blur 
the clinical aspect and render it therefore considerably 
more difficult to plan a definite course of treatment. Pa- 



290 AUTHENTIC TWILIGHT SLEEP 

tients with somnolent conditions (for instance, when sus- 
pected of typhus, perityphlitis, peritonitis) and such con- 
ditions in which eventual interruption of the conscious- 
ness (acute anaemia in placenta prsevia) may be expected, 
would not have to be excluded from the use of Dammer- 
schlaf. I do not consider it necessary to desist from the 
use of scopolamin-morphin injections as an aggravation; 
besides, the loss of consciousness will be apparent from 
sufficient other significant symptoms. I do not even think 
it desirable to desist, in the case of eclampsia, for in such 
cases the injections have a beneficially soothing and pain- 
blunting effect. 

Besides these cases which might be thought of as coun- 
ter-indications, I do not deem it necessary to consider any 
others. 

I herewith condense the result of my work as follows : 
The Dammerschlaf produced by scopolamin-morphin is 
able to limit the suffering of the woman in labour to the 
lowest minimum imaginable. 
This object is attained: 

Without disagreeable secondary effects upon the sub- 
jective condition of the mother in labour. 
Without substantial interference with the labour it- 
self. 
"Without danger to the mother. 
Without injury to the child. 
The scopolamin-morphin Dammerschlaf renders pos- 
sible a truly humane execution of the didactic duties of 
the institutes of learning without tormenting interference 
with the women in labour. 






APPENDIX II 291 

The scopolamin-morphin Dammerschlaf during birth, 
therefore, is a method till now unparalleled, and proves to 
be a blessing to the doctor and the patient, to the clinical 
instructor and the disciple. 



APPENDIX HI 

FUKTHEK EXPEKIMENTS IN DAMMEKSCHLAF 
By Db. Gael J. Gauss 

Karlsruhe Address, Conference of German Naturalists and Doctors 

1911 



There are now 8,000 cases of the use of scopolaiiiin- 
morphin in obstetrics, 3,000 of them in the FrauenHinik 
at Freiburg. In the six years of the Dammerschlaf at 
Freiburg there has been no change in the technique, so that 
the 3,000 furnish homogeneous statistical material as a 
touchstone on which to test other groups. 

Danger to the mother never occurs if deep narcosis is 
avoided. On this point most authors are just as clear as 
we are at Freiburg. The deaths for which the method has 
been held responsible cannot be laid to its charge. Under 
our method the mortality of mothers shows no increase. 

There is likewise no danger to the child if Freiburg 
directions are observed. All authors who report dead 
children have deviated from the Freiburg rules. The oc- 
casionally observed oligopnea of the newborn children is 

292 



APPENDIX III 293 

a symptom which every child brought to birth with the 
forceps also exhibits, without anybody attaching any im- 
portance to it. Cases of asphyxia do not occur more fre- 
quently than in ordinary practice. As Hoche expresses it, 
sequelae in later life should be referred to the realm of 
fiction. Retardation of the birth and increase of the fre- 
quency of operation need only be expected if, by a wrong 
technique, an actual narcosis is produced. 

The avoidance of unpleasant accessory effects and the 
obtaining of the proper and safe Dammerschlaf are en- 
tirely dependent on the strict observance of the rules given 
for the method. Imperfect understanding of these rules 
has often and in various ways led to bad results. A con- 
scientious following of them, on the other hand, guaran- 
tees the obtaining of Dammerschlaf in the vast majority 
of cases ; that is, up to 82 per cent. On the basis of the 
experience of six years, with 3,000 births under scopola- 
min in our own clinic, it still can be maintained that the 
Dammerschlaf is to be looked upon as devoid of danger, 
and a great blessing. 

Since in 1864-67 ether was introduced for narcosis by 
Jackson and Morton, and chloroform by Simpson, there 
has been a never-ending controversy as to which of the 
two drugs is the better. Those who advocated either the 
one or the other were nevertheless agreed upon one point : 
that was that in both methods death and undesirable ac- 
cessory effects occurred which could not always be avoided. 
This fact was the basis of all those endeavours which 
aimed at replacing narcosis by chloroform and ether, by 
new drugs and new methods. 

The honour has been done inc of entrusting me with the 



294 AUTHENTIC TWILIGHT SLEEP 

task of speaking to you of one of these substitutes, namely, 
of that method which seeks by the injection of scopolamin 
and morphin to reduce the dangers of general narcosis. 

I think I ought to give you a general idea of the phar^ 
macological side of the subject : namely, (1) in what forms 
the scopolamin-morphin is given; (2) what are the advan- 
tages and disadvantages of the various methods of admin- 
istration; (3) what are we, with our present clinical ex- 
perience, entitled to look on as definitely the advantages 
for ourselves and our patients ? 

The specific action of scopolamin-morphin as a narcotic 
was first recognised and tested by Schneiderlin and Korff 
in Freiburg in 1900. They started from the idea that a 
combination of the two alkaloids must be a particularly 
happy one, as their anaesthetic and hypnotic effects are 
common to them, while their remaining properties are al- 
most without exception antagonistic. It was consequently 
to be expected that a summation of the desired narcotic 
action would be accompanied by the simultaneous diminu- 
tion of their dangers. 

As a matter of fact, recent laboratory researches have 
made it appear probable that in scopolamin-morphin we 
have not, as was formerly believed, two independent sub- 
stances acting in conjunction, but a new combination that 
acts in a completely different way from its individual com- 
ponents. 

In addition to the improvement of the narcotic action 
by this combination, a number of additional advantages 
are to be observed, which may be briefly mentioned. These 
are: reduction of salivation, diminution of nausea, and 
the abolition of the subjective unpleasantness which ac- 



APPENDIX III 295 

companies the initial stages of every inhalation narcosis — 
that is, feelings of terror and suffocation. 

No douht there are also disadvantages in the physio- 
logical effect to be set against these advantages : increased 
frequency of the pulse; distention of the blood vessels in 
the head region; insufficient relaxation in spite of large 
doses; an ill effect on the respiration; very great thirst, 
and variability in the action. 

On account of these disadvantages, substitutes for both 
components were sought. Instead of morphin, pantopan 
was used. But the experimenters did not succeed in mate- 
rially reducing the bad effects upon the respiration which 
had been due to the morphin. In this respect narkophen 
gave better results, but was in so far inferior that the nar- 
cotic action occurred later and the analgesia appeared to 
be greater than the clouding of the consciousness. The 
clinical experience with narkophen is without doubt, so 
much can be said already, in all respects favourable. Like 
morphin, it appears to involve no danger if reasonable care 
is exercised in the dosing. 

Attempts have also been made recently to evade the 
unaccountability or instability of chemical composition of 
scopolamin by the use of atropin. But the action of atro- 
pin is by no means as satisfactory as that of scopolamin. 

On the other hand, to judge from my own clinical ob- 
servations, it is quite possible that this seeming unaccount- 
ability of the drug is only the expression of individual and 
extraordinary sensitiveness in various patients, or even in 
the same patient at different times and under different 
circumstances. Both the careful adaptation of the dose to 
the individual (old people, for instance, can stand much 



296 AUTHENTIC TWILIGHT SLEEP 

less) and an increase of the keeping qualities of the drag 
by the addition of chemicals remove this objection com- 
pletely. 

What, then, have the clinical results to tell us? The 
number of cases of pure scopolamin-morphin narcosis is 
great enough to enable us to form an opinion of the meth- 
od. The ever-recurring observation is that small doses 
were not sufficient for major operations, which require 
complete relaxation of the muscles. But if the dose was 
increased, and this was done up to .0036 scop. + .045 
morph., unfavourable accessory action on respiration and 
circulation was observed, which sometimes even caused 
death. 

Judging from all observations made, there can be no 
doubt that for major operations the use of scopolamin- 
morphin alone cannot be recommended without danger. 

The case of minor operations is quite a different one. 
In them much smaller doses suffice, which involve no dan- 
ger to the patient. To these belong all those which require 
only a reduction of pain with greater or less clouding of 
the consciousness ; methods of examination which are sub- 
jectively disagreeable to the patient, such as cystoscopy or 
rectoscopy, and numerous therapeutic operations, such as 
curettage. In this respect our technique has been greatly 
improved, especially in consequence of the experience 
which we obtained in obstetrics. 

Since Steinbuchel ? s first attempts to make scopolamin- 
morphin of use in obstetrics between 8,000 and 10,000 
births have been observed in which this combination was 
employed. The results appear to be extremely contradic- 



APPENDIX III 297 

tory: on the one hand, warm advocacy; on the other, 
brusque rejection of its use for births. 

Closer examination gives a very simple explanation of 
these contradictions ; for different methods, with technique 
differing in principle, must naturally lead to quite differ- 
ent results: Steinbiichel, Hocheisen, and Dammerschlaf 
are three distinctively different methods. 

Steinbiichel used one rather small dose of scopolamin- 
morphin, repeating the same dose when necessary. Hoch- 
eisen used one dose generally large, sometimes very large. 
In some cases he did not repeat ; in others he repeated the 
full dose as soon as signs of painlessness appeared, though 
painlessness is a sure sign of overdosing. Dammerschlaf 
uses one initial dose, small or of medium size. It seldom 
repeats the morphin — at most once, in half a dose. Fur- 
ther doses of scopolamin are a third the size of the first 
dose, and they are given only when signs of memory ap- 
pear. This insures the minimum dose for attaining prac- 
tical painlessness ; this constant limitation to the minimum 
dose insures against overdosing, with its possible bad ef- 
fects on mother, child, and birth process. 

These facts are not only important to the obstetrician ; 
they have also a practical interest for the surgeon and 
gynaecologist. The doses given in a unit of time to obtain 
the Dammerschlaf used in obstetrics are also used in oper- 
ations in which it is necessary to resort to supplementary 
inhalation narcosis on account of the failure of the rela- 
tively too small scopolamin dose. That is to say, we have 
here a new application of the scopolamin-morphin action, 
a preparatory action. 

All these authors unanimously remarked that in addi- 



298 AUTHENTIC TWILIGHT SLEEP 

tion to the advantages of a preliminary narcosis, one fact 
was most striking: namely, a reduction in the amount of 
inhalation narcotic used. 

In the Freiburg Frauenklinik exact investigations have 
been made concerning the extent to which we economise 
the use of chloroform-ether, by using scopolamin-morphin. 
These showed in a group of 192 major gynecological oper- 
ations in which the Roth-Drsegers chloroform-ether-oxygen 
apparatus as adapted by Kronig was used, that in the 
case of 90 women without scopolamin-morphin .29 cc. 
chlor. + 2.22 cc. ether; 102 women with scopolamin- 
morphin .14 cc. chlor. + 1.69 cc. ether per minute were 
necessary to maintain sufficiently deep narcosis. This re- 
duction in the inhalation narcotics must simultaneously 
cause a reduction in the risks : that is, if the principle of 
mixed narcosis is correct. According to the latest labora- 
tory investigation, it may be said that this principle is no 
longer in doubt; more especially as clinical experience 
confirms these results. Indeed, this has been carried still 
further. 2sTot only scopolamin has been used as a prelim- 
inary drug, a whole series of other drugs were used in 
addition, in order, as much as possible, to reduce the dan- 
gers of each by means of the others. A narcosis in many 
clinics, including Freiburg, is constituted, for example, as 

follows : 

Veronal 1.5 
Veronal .5 
Sc- M. 2 or 3 doses 

.0006-.00075; 1.5-2 cgr. 
Main Narcosis. 

With regard to the virgin narcosis, whether ether, chlo- 
roform, or A. E. C, opinions differ greatly ; but it is cer- 






APPENDIX III 299 

tain that for all, the preparatory action of the scopolamin- 
morphin is equally favourable. 

To sum up, scopolamin-morphin is used : 

(1) For main narcosis — a dangerous use. 

(2) As preliminary narcotic before inhalation nar- 

cosis. 

(3) For minor operations, examinations, etc. 

(4) As preliminary narcotic before local, stovaine, 

etc., spinal or lumbar anaesthesia, the injec- 
tion of morphin without scopolamin is itself a 
principal operation. 

For some of these uses also scopolamin 
without morphin is sometimes used. 

(5) As obstetrical seminarcotic for producing con- 

dition of clouded consciousness. 



II 



Dammerschlaf in obstetrics has one property in common 
with other methods: namely, that it was enthusiastically 
welcomed by some and opposed and rejected with equal 
energy by others. After the pros and cons in theory and 
practice had waged an indecisive struggle for seven years, 
the question has now reached a new stage. We have now 
in possession statistics of a sufficiently large number of 
births — over eight thousand, of which there were three 
thousand in the Freiburg Frauenklinik. 

As no material alterations have been made in the di- 
rections laid down by me for the technique of Twilight 
Sleep six years ago, these 3,000 Freiburg births constitute 



300 AUTHENTIC TWILIGHT SLEEP 

very homogeneous statistical data to serve as a touchstone 
for the value of the methods used elsewhere. So do not 
expect me on this occasion to describe the advantages of 
the Twilight Sleep. Our patients can describe them much 
better than we. I only desire to prove here that it is the 
Twilight Sleep that has itself refuted the bad reputation 
given it in some quarters. 

I will begin with the most important point in the hos- 
tile criticism: namely, the alleged danger to the mother. 
It makes one's hair stand on end when one reads that 
child-bearing patients in Twilight Sleep have a respira- 
tion reduced by as much as four breaths in the minute, a 
pulse increased to 150 beats, and a temperature rising to 
as much as 39 degrees. This can only be a confusion with 
gynaecological surgical narcosis which does not hesitate to 
administer as much as .0036 in three hours. Even then 
there must be in addition a further confusion with lumbar 
anaesthesia with which alone subsequent rises of tempera- 
ture have been observed. To this category belong the 
mortality of 3.3 per thousand (0/00) mentioned by 
Strassny, and the oft-quoted Toth case (Tauffer), in which 
.0003 — Wertheim — haemorrhage — and relaparotomy — 
(Death). 

To this category belong his statements about the danger 
of death later on, from heart collapse and suffocation. 

Obstetrical literature records only one death laid to 
the charge of scopolamin: namely, the one recorded by 
Bardeleben. The formula for this is .0003 — spontaneous 
birth — haemorrhage — death after 9 hours — postmortem, 
anaemia and weak heart. 

In accordance with the majority of authors who regard 



APPENDIX III 301 

scopolamin as devoid of danger for the mother, the injec- 
tion cannot be regarded as the cause of the mother's death 
one single time in all our cases. Our maternal mortality 
of .0033 is ten deaths, among which there was one with 
placenta prsevia, one with colporrhexi3 with funnel-shaped 
pelvis — both these from haemorrhages. Eight died of puer- 
peral fever. The septic cases (with .2 per cent, puerperal 
mortality) are due to two separately occurring house en- 
demics. Those from angina each took place during 
courses of instruction for midwives. 

The morbidity in the various years ranged from 1.7 per 
cent, to 10 per cent., and amounted on an average to 7 
per cent. That is certainly not a worse figure than is 
shown in other clinics. 

The point second in importance — the occurrence of dan- 
ger to the child — occupies a much larger space in the liter- 
ature of the subject. The Twilight Sleep is said to be re- 
sponsible by direct poisoning for seven dead children. If 
we investigate these cases more closely, we find among 
them : One diaphragmal hernia (Gminder) ; one necrosis 
of the roof of the skull (Avarffy), due to pressure; one 
double pneumonia (Avarffy) ; one lues (Hocheisen) ; and 
one Thymus death (Meyer) ; the cause of death was in 
each case ascertained by postmortem. Of the seven, there- 
fore, there remain only two, one of which died after ap- 
plication of the forceps (Hocheisen) whilst the other 
(Bass) died with symptoms suspiciously like those of 
morphin poisoning. 

Our own statistics show a child mortality of 1.3 per 
cent., not including premature births, monstrous births, 
and children already dead. We have not lost a single 



302 AUTHENTIC TWILIGHT SLEEP 

child with symptoms of scopolamin-morphin injection in-, 
toxication. 

With regard to the children, moreover, one must not 
forget that a certain death rate will always remain un- 
avoidable, and that those cases which hitherto without 
scopolamin did not permit of the assignment of a definite 
cause of death must not now be all of a sudden attributed 
to the Dammerschlaf. This is all the less justifiable as 
AschofT's theory actually goes to show a reduction of 
breathing in liquids. And even though at present this is 
only a theory, the following facts speak in its favour: 
(1) the statistics with 1.3 per cent, mortality as against 
3.4 per cent., from 1895 to 1904; (2) the condition of 
the newborn children. This condition of the newborn has 
been also the object of attack. Asphyxia and oligopnoea 
are universally represented as very serious results of Twi- 
light Sleep. Among our children who were born alive, I 
find 80 per cent, recorded as brisk and lively, 16 per cent. 
as oligopnoeic, and 5 per cent, as displaying asphyxia. I 
must again remark that oligopnoea can be looked upon as 
entirely devoid of danger if it is not caused by large quan- 
tities of morphin, to which drug the infant organism is 
extremely susceptible. Holzbach's investigations have 
taught us that the child comes drunk into the world when 
the scopolamin is injected shortly before into the mother, 
and still remains in its circulation. But oh the other hand 
it is born bright and lively when the scopolamin it con- 
tain's has been dealt with and has already been thrown off 
by the circulation into the urine. Strassmann has recently 
again recommended anaesthesia a la reine, and maintains 
with regard to chloroform that when in the child's blood 



APPENDIX III 303 

it has less action because the medulla of the nerves and the 
grey substance in the central organ of the child are still 
only very imperfectly developed. What is sauce for chlo- 
roform is surely sauce for scopolamin! 

What about asphyxia? It never occurs as the direct 
result of scopolamin. Whether it arises indirectly from 
the Twilight Sleep, or whether it is occasioned by deferred 
birth can be determined from the following considerations : 
(1) From the frequency of asphyxia; this is 5 per cent., 
which is not more than where no scopolamin is used. (2) 
From the mortality, so far as this is the result of asphyxia. 
(3) Prom the effects which may develop in later life; 
this last criticism has been answered very effectively by 
Hoche, who calls it a comic fable. 

But facts are always firmer ground than theory. I 
therefore caused inquiries to be made by Salzberger as to 
the condition of 500 scopolamin children who had attained 
the age of one year. Prom the 421 replies it appeared that 
there were 11.6 per cent, deaths in the first year, while the 
mortality in this year in Baden was 16 per cent. Al- 
though Strassny looks upon this favourable result as not 
yet conclusive, nevertheless I draw from it the deduction 
that our scopolamin children have during the first year of 
life suffered no injury from scopolamin. To crown all, 
Hanner comes to our assistance with further favourable 
results. 

In the opinion of many alienists, oligopnoea has an etio- 
logical importance in the origin of what seems to be 
Spartan contraction, of Little's disease, and of idiocy. 
They found, for example, that 4 per cent, of children born 
with asphyxia become idiotic, that one-sixth of them learn 



304 AUTHENTIC TWILIGHT SLEEP 

to walk late, and one-ninth of them to speak late. Hanner 
tested these results which had been arrived at on the 
ground of anamnestic data on 450 children of the Breslau 
out-patient department. He found that difficult birth 
with asphyxia of the child did not dispose to abnormal 
mental development or idiocy, more than normal birth. 
It is interesting to note that through the fault of the mid- 
wife Goethe was born with asphyxia, according to Mobius. 

If it is, then, to be considered as highly probable that 
the application of scopolamin, even in the form of over- 
dosing, may be taken to be devoid of direct danger, 
whether to mother or child, it may easily be supposed that 
it may cause injurious effects indirectly, in the matter of 
birth-pains, straining action, and post-natal haemorrhage. 

It is beyond all doubt that these deleterious effects may 
appear if too great doses are given. Since an influence on 
the motor force of the uterus would make itself most 
clearly apparent in the frequency with which the use of 
the forceps or placental operations became necessary, I will 
bestow some little attention on this point. The literature 
mentions that the frequency with which the forceps was 
used amounts to 20 per cent., and could easily be raised to 
100 per cent, if one used it wherever indicated. 

The frequency of forceps cases in Freiburg has settled 
down to an average of 6 per cent, to 7 per cent. As the 
subjects of all forceps applications made for demonstration 
are sent into Dammerschlaf for this particular purpose, 
this is a figure that need not fear the light of day. 

The frequence of manual placenta detachment ranges 
between .2 per cent, and .6 per cent., and has an average 



APPENDIX III 305 

of A per cent. This is a smaller figure than is to be found 
in most statistics. 

To come to the principal object itself, the anaesthetising 
and narcotising action of scopolamin-morphin, after this 
preliminary consideration of the adventitious effects, I 
should like to direct your attention to the fact that the 
expression "failure" used in the literature is as a matter 
of fact not at all appropriate. 

The second method of using scopolamin-morphin is es- 
sentially not Dammerschlaf, but a reduction of the suffer- 
ings during birth ; and this, in spite of Mansf eld's opinion, 
is, as a matter of fact, accomplished in every case. Twi- 
light Sleep is accomplished successfully when there is an 
adequate abolition of the apperception of pain. It is to 
be looked upon as a kind of subconsciousness, in which the 
cortex of the cerebrum is, according to the investigations 
of Pinck, completely cut off from the reflex columns of 
the spinal cord. 

Strassny's custom of waiving aside the explanation of 
this peculiar and hitherto unknown state of consciousness, 
with the unmannerly remark that it is a doctoring of the 
facts to speak of painless birth, is inconsistent with the 
dignity of scientific investigation. Whatever Strassny 
may say, the Twilight Sleep still appears to us and to our 
patients as a condition well worth the trouble of attaining, 
and pleasant to experience. 

With regard to the effect, I have now to state that we 
obtain Dammerschlaf in from 63 per cent, to 65 per cent, 
of births; a marked reduction of suffering in 22 per cent., 
and no effect in from 13 per cent, to 15 per cent. The ab- 
sence of effect may have been occasioned by too long de- 



306 AUTHENTIC TWILIGHT SLEEP 

ferred injection, or by refractoriness to anaesthesia on the 
part of the patient. To this it is due that in the first class 
we had 82 per cent. Dammerschlaf ; in the second, 66 per 
cent.; in the third, 59 per cent., and in the fourth, 56 
per cent. 

How conies it, then, that such a great difference exists 
between results in Freiburg Klinik and those of other 
authorities ? 

It does not lie in any lack of sober-minded observation, 
as Herr Bumm thought fit to say five years ago. A con- 
siderable factor in the explanation is supplied by the 
prejudice with which various obstetricians, on their own 
admission, entered on their investigation. 

Steffen, for example, of the Dresden clinic, says in his 
paper that he knows of no more pleasing sight than that of 
a strongly built woman giving birth to a first child with 
strong and painful birth-pangs. 

Avarffy, as quoted by Barsorsy, acknowledges openly 
that he had recourse to the Dammerschlaf only under com- 
pulsion. Hocheisen regrets that he is compelled by the 
demand of the public to employ a poison that is so terrible 
and so unreliable, and — as it seems to me not without a 
certain malicious pleasure — he records all the injurious 
effects on a card which shows in a hundred births 134 
interferences with the normal course of birth! The best 
method would break down with such a point of view as 
these represent as the basis of an investigation of its value. 
This is especially true of the Dammerschlaf, which more 
than any other requires to be employed with sympathy and 
an open-minded desire to make the most of it. It is con- 
sequently no wonder if the reports of the authors just men- 



APPENDIX III 307 

tioned do not precisely constitute a hymn of praise to the 
'Dammerschlaf. 

Second in importance, external circumstances ranked as 
obstacles to success. The lack of sufficient obstetrical staff 
is the first obstacle ; for, as Mansf eld says, we can form no 
idea of what enormous care, trouble, and continuous 
watching a well-conducted Twilight Sleep demands. 
Fehling mentions the fact that not every young doctor 
displays capacity for carrying out the method. 

I learned also from private sources that in other clinics, 
the passive resistance of the midwives has led to the re- 
linquishing of the method. Finally, the correct technique 
has often not been employed, and this, unfortunately, in 
very many clinics. In addition, we may assume that not 
every assistant in all clinics who is getting experience in 
the delivery room is given the careful instructions about 
the Dammerschlaf that we are accustomed to give, espe- 
cially in the memory tests. This is by itself sufficient to 
make the proper action of the Dammerschlaf problemati- 
cal. As early as 1907 I wrote an emphatic warning: 
"The special action and the safety of the Dammerschlaf 
are based solely upon the testing of the powers of memory, 
and by this method we must stand or fall." With regard 
to this passage, Mansf eld expresses himself as follows: 
"It is really extraordinary that publications written in 
perfectly clear German can be so misinterpreted." Hoch- 
eisen, Messer, and many others have, however, come for- 
ward as opponents of the Dammerschlaf without paying 
any attention to this, the very foundation of the method, 
and this is just what cannot be done with impunity. 

The Twilight Sleep is a narcotic condition of extremely 



308 AUTHENTIC TWILIGHT SLEEP 

limited breadth, like a narrow mountain crest. To the left 
of it lie the dangers of too deep action, with narcosis and 
absence of birth-pains; to the right, the danger of too 
shallow action, with retention of consciousness and sensi- 
bility of pain. The power of memory is and remains the 
only guide. If we cling to it, and to testing it in strict 
accordance with the rules laid down, then the Twilight 
Sleep is devoid of danger, as is shown by our statistics, 
and is a great boon, as is proved by the gratitude of our 
patients. 



BIBLIOGRAPHY 

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Gminder, 100 Ealle von Morphium-Skopolamin-lSrarkose 

309 



310 AUTHENTIC TWILIGHT SLEEP 

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BIBLIOGEAPHY 311 

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312 AUTHENTIC TWILIGHT SLEEP 

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BIBLIOGEAPHY 313 

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American Journal of Obstetrics, December and Jan- 
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Cincinnati Lancet Clinic, many issues. 
New York Medical Journal, many issues. 



314 AUTHENTIC TWILIGHT SLEEP 

Journal of American Academy of Medicine, June 

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GENERAL 

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316 AUTHENTIC TWILIGHT SLEEP 

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